February 2020 Strategic Outline Case

February 2020

Christopher Roe Senior Consultant

Turner & Townsend Consulting Limited One New Change London EC4M 9AF

t: +44 (0)20 7544 4000

e: [email protected] w: turnerandtownsend.com

Strategic Outline Case Report

Kempston MCCC and Wootton GP surgery

Bedford Borough Council

making the difference



Turner & Townsend

Contents

1 Introduction 4

Executive Summary 4

Background to this document 4

Purpose of this document 5

How this document was produced 6

2 Strategic Case 7

Policy 7

Location 17

Equality and Diversity 20

Healthcare activity demand and capacity projections 20

Space requirements 22

Rationale and Objectives 24

Risk 28

3 Economic Case 29

Introduction 29

Locations 29

Evaluation Criteria 34

Options Appraisal 42

Development Appraisals 45

Risks 45

NPV, Optimism bias and sensitivity analysis 45

Cost Benefit Ratio 45

Summary 46

4 Commercial Case 47

Procurement Strategy 47

SOC to FBC Process 53

Attractiveness to the market 54

Timetable for procurement 55

5 Financial Case 56

Capital Costs 56

Rent Reimbursement 57

Other building Costs 57

VAT Treatment 58



Turner & Townsend

Revenue affordability 58

CCG Rent Reimbursements 58

Sensitivity analysis 58

Summary of Financial Case 60

6 Management Case 61

Approvals and Support 61

Project Management 61

Governance Arrangements 63

Operation of the buildings 63

Organisational Changes 64

7 Conclusion 67

Summary of recommendations 67

Next Steps 67

Appendix 1. Other National Policies 69

Appendix 2. Stakeholders 74

Appendix 3. GP Interviews 75

Appendix 4. Risk Register 76

Appendix 5. Site assessment criteria 77

Appendix 6. Site Scores 78

Appendix 7. Presentation to Mayor of Bedford 79

Appendix 8. Police Station Site Financial Appraisal 80

Appendix 10. Cost benchmarking 86

Rev Status Originator Approved Date

1.0 Final Draft Christopher Roe Claire Colgan 05 February 2020 1.1 Final Draft Christopher Roe Claire Colgan 24 February 2020

© Turner & Townsend Consulting Limited. This document is expressly provided to and solely for the use of Bedford Borough Council on the Kempston MCCC and Wootton GP surgery and takes into account their particular instructions and requirements. It must not be

made available or copied or otherwise quoted or referred to in whole or in part in any way, including orally, to any other party without

our express written permission and we accept no liability of whatsoever nature for any use by any other party.



Turner & Townsend 04

1 Introduction

Executive Summary

Bedford Borough Council (BBC), in partnership with Bedfordshire Clinical Commissioning Group

(BCCG) have commissioned this Strategic Outline Case (SOC) to identify a viable way of addressing

constraints within the delivery and capacity of primary care in Kempston.

This study has identified that delivery of a multi-speciality community care centre (MCCC) would

address an existing under-provision of GP and primary care space and facilities in Kempston whilst

simultaneously improving the robustness of the existing Primary Care Network (PCN).

A detailed study of the existing services, patient numbers and services that are planned to be

delivered through the PCN in the community has established that a significantly larger primary care

estate is needed to enable adequate healthcare to be offered to local residents. Having reviewed

the existing estate and the need to provide 2.5 times more primary care space in Kempston than

currently exists, it has been confirmed that none of the existing sites are suitable, or able to be

expanded/modified to meet the current and future needs of patients and healthcare professionals.

As a result, this SOC has study all potential development sites in Kempston and concluded that the

Kempston Police Station, located in the town’s centre provides an ideal location for a new MCCC.

The Police have commenced preparations to decommission this site which will culminate in its

disposal by mid-2022. The site benefits from good transport links, a central location and is the

appropriate size for the proposed MCCC development. This SOC has also considered other sites

including the former Robert Bruce site. Although offering a cleared site, its complex land

negotiations, multiple stakeholders and sub-prime town centre location mean that on balance it is

not favoured by this SOC.

This SOC concludes by assessing the initial viability of the site and setting out the next steps

needed to be taken at the Outline Business Case (OBC) and Full Business Case (FBC) stages to

build on the scope set out in this document.

Background to this document

Through significant housing development across Bedfordshire over the last 20 years, demand for

all healthcare services, including primary care, has increased. Due to the complexities that

surround primary care provision, it has not been possible to maintain adequate primary care

services, which are now out striped by demand. Recognising this shortfall, and the benefits that

can be attained through collaboration, BBC and BCCG came together and jointly prepared the

BCCG Primary Care Estate Strategy (May 2019).

The strategy highlighted identifies the key care needs of the Borough including:

The high level approaches to delivering a primary care network

The key care ‘Hubs’ across the Borough, one of which would be in the town of Kempston.

The potential benefits to be gained from the “relocation of King Street, Cater Street and St

Johns Street Surgeries into one Hub facility in Kempston, with potential to provide a range

of other health and community services from the same building”.




Purpose of this document

This document is structured in the format of a ‘Strategic Outline Case’ (SOC) detailing the strategic

argument for the development of a MCCC as a means of addressing an existing under provision of

GP and primary care service in Kempston.

A SOC should specifically address the following:

Appraisal

element

Key questions

Function What services will be provided?

Which GPs will be present?

What other health or social care providers will use the building?

Size How big is the population?

How many people will use the service?

How many clinical rooms?

How much office space (including meeting rooms and ancillary space)?

How many car parking spaces?

Projected growth in population and how that growth will be

accommodated by the Hub.

Location Where will it be?

How will people get there?

Are the public transport routes suitable?

Are there any abnormal characteristics of selected sites?

What remedial works will be required in order to provide the space?

Funding

routes

Which funding routes are available to support the development?

How much S106 contribution monies will be available?

What is the gap?

What work needs to be done in order to support funding applications?

Ownership What ownership models are available to support the development?

Are there any other interested partners in the Public Sector?

Are there any opportunities for third party developers?

Table 1 – Focus of SOC

To do so, the SOC will present the case for developing the MCCC hub in Kempston by identifying

the possible uses and operation of this building together with the potential size and location of the

MCCC. This information will be presented with sufficient facts and insights to allow the BCCG

Governing Body and BBC to decide if the concept is feasible and capable of being taken forward,

leading to the production of an outline business cases and in turn a full business case.

The principle of a MCCC has previously been considered by the Bedford Borough Primary Care

Estate Strategy. This is in response to, and in recognition of, the local imperative, reflecting the

national position, to take positive action in respect of the growing demand faced by health and care

services in the coming years. The estate strategy identified that this demand was generated by,

but not exclusively the result of, a significant increase in the local population of Kempston.




Whilst this work considers the requirement for existing primary care services to work more

collaboratively, as these are existing services, greater concentration has been given to identifying

an estate solution that is capable of meeting the needs of Kempston.

There are four key strategic questions for consideration:

1. Can the MCCC provide a facility where services can come together, locally, to match support to

individuals’ needs avoiding the present requirement to refer patients to a number of services in

different buildings, hospital and using local information to help identify needs sooner, to

improve people’s health and wellbeing?

2. Can a MCCC improve the ability of health and care organisations to attract and retain staff,

whilst using their existing workforce more efficiently through the benefits of economies of

scale?

3. Is the MCCC able to operate to a higher degree of cost efficiency than the existing estate,

reducing overheads, improving service delivery and long-term viability?

4. Will the MCCC be able to maximise value from the investment to ensure it is able to respond to

changes and new developments in the primary care sector with minimal changes to the

building?

How this document was produced

This document has been produced in partnership between the Local Authority, BBC and BCCG with

input from local stakeholders, including GPs and primary care providers.

Information from these groups and organisations was combined with local data, such as

demographic, property and health information to develop this SOC. All data sources and minutes of

meetings with organisations and individuals have been included in this SOC to enable verification to

take place at the Outline Business Case (OBC) and Full Business Case (FBC) stages.

The diagram below illustrates the process followed to develop this SOC:

Figure 1 – How this document was produced




2 Strategic Case

In this section of the SOC we illustrate how the MCCC proposal aligns and meets national and local

healthcare priorities. This is achieved by examining national guidance form the NHS and local

objectives as set out by the Local Authority, CCG and Sustainable Transformation Partnership

(STP).

Policy

2.1.1 Strategic context

2.1.1.1 National policies

NHS England is responsible for arranging the provision of health services in England. The mandate

to NHS England sets the Government’s objectives and any requirements for NHS England, as well

as its budget. In doing so, the mandate sets direction for the NHS and helps ensure the NHS is

accountable to Parliament and the public.

Every year, the Secretary of State must publish a mandate to ensure that NHS England’s objectives

remain up to date. This mandate is based on the shared priorities of Government and its partner

organisations for health and care – the priorities we believe are central to delivering the changes

needed to ensure the NHS is always there whenever people need it most. As leader of the

commissioning system, but working with others, NHS England has a central role to play.

This mandate sets objectives for NHS England that reflects its contribution to these ambitions to

2020.

NHS England has seven key ambitions that underpin their operational activities:

i Through better commissioning, improve local and national health outcomes, particularly by

addressing poor outcomes and inequalities.

ii Help create the safest, highest quality health and care service.

iii Balance the NHS budget and improve efficiency and productivity.

iv Lead a step change in the NHS in preventing ill health and supporting people to live healthier

lives.

v Maintain and improve performance against core standards

vi Improve out-of-hospital care

vii Support research, innovation and growth.

The MCCC is set to fulfil many of these objectives by significantly enhancing the capacity

of primary care in Kempston with modern facilities and at a scale that will unlock cost-

effective primary care treatment in the community, without the need to rely on hospital

services.

2.1.1.2 NHS Long Term Plan

The NHS Long Term Plan sets out the vision for the provision of health services over the coming

decade. It identifies where and how changes need to be made to keep it in pace with those

requiring is services. Part of this focus is on providing more support and a joined up approach to

care at the right time, in the optimal setting.




The Plan aims to achieve this by focusing at a PCN level to encourage GPs to work more

collaboratively in commissioning a range of services to meet the needs of the local population.

These newly expanded community health teams will be required under new national standards to

provide fast support to people in their own homes as an alternative to hospitalisation, and to ramp

up NHS support for people living in care homes. Within five years over 2.5 million more people will

benefit from ‘social prescribing’, a personal health budget, and new support for managing their own

health in partnership with patients’ groups and the voluntary sector.

The MCCC will allow more people to receive a wider range of healthcare services in their

home and community by becoming a focal point for the local PCN. By providing a facility

to GPs and other community and healthcare practitioners to work in a single facility, care

will be more coordinated and tailored to the needs of the individual.

2.1.1.3 GP Contracts (2019)

In 2019 GP’s contracts were updated to reflect the Long Term Plan as well as respond to current

and emerging needs within the health environment. Central to this is how GP’s and their contracts

respond to the rollout of PCNs across the country. Most notably within this was the drive to

increase staffing numbers to meet these news services. In total 22,000 additional staff are

expected to be working within primary care by 2024. At an individual surgery level this translates

to an average 3 additional healthcare practitioners per surgery.

The proposed MCCC has been developed specifically to the new requirements that the

PCN creates. By advocating the provision of more services at a local level, and increasing

staffing levels of primary care it is essential that the estate is enlarged to support these

expanded provisions. This SOC has calculated the expected amount of clinical space

needed to support GMS and PCN services.

2.1.1.4 One Public Estate (OPE)

The production of this SOC has been funded through OPE. Established to provide practical,

technical support and funding to public sector organisations to deliver ambitious property-focused

programmes in collaboration with central government and other public sector partners. This SOC

will propose how the identified primary care health care improvements will fulfil the objectives of

OPE of economic growth, integrated services and generating efficiencies.

This SOC sets out a more integrated, and patient focused approach to health care, made

possible by the bringing together of geographically disparate services into a coordinated

hub.

2.1.1.5 Primary Care Networks (PCN)

BCCG is in the process of rolling out its PCN across Bedfordshire. Refreshing NHS Plans for 2018-19

set out the ambition for CCGs to actively encourage every practice to be part of a local primary

care network so that these cover the whole country as far as possible by the end of 2018/19.

Primary care networks contain geographic populations of 30-50,000 patients and consequently

around 1,300 have been created across England. They will be expected to think about the wider

health of their population, taking a proactive approach to managing population health and, from

2020/21, assessing the needs of their local population to identify people who would benefit from

targeted, proactive support.

In time, the PCN will be required to delivery seven national service specifications. To do this they

are expected to work more collaboratively to provide services that might otherwise not be possible




from a standalone surgery through joint commissioning. This has already commenced and roles

such as social prescribers are being fulfilled at a PCN level.

The three GP surgeries that service Kempston are within the Caritas Medical PCN which supports

approximately 44,000 people residents through its five surgeries of:

Shortstown

King Street

Queens Park

St John

Cater Street

Wootton Vale.

The three surgeries of Cater Street, King Street and St John have been identified in this document

as they are all within Kempston. The remaining three surgeries are in neighbouring villages and

whilst part of the same PCN, do not have the same estate related issues as their Kempston

counterparts. Local strategies discussed below have identified that addressing the estate issues in

Kempston will alleviate the challenges faced by these surgeries and provide a central hub from

which a wider range of services can be brought forward and shared by the whole PCN.

This SOC aims to set out the case for bringing these surgeries into a single central

location and providing them with the facilities needed to deliver the wide range of PCN

and out of hospital services the community requires.

2.1.1.6 Primary Care Home Model

Developed by the National Association of Primary Care (NAPC), the model advocates the colocation

of and health and social care to provide personalised services better equipped to offer preventative

care for the local community.

In the model health care professionals come together to provide GP, mental health, social and

acute care. It is also provides a formal route for the voluntary sector to provide services. Sitting

within the PCN, the mix of services can be refined according to the needs of the local community.

The proposal set out in the document aims to achieve these objectives by bringing

together GPs and other primary health care professionals in a new purpose-built facility

with sufficient space to meet the needs of the local community.

2.1.1.7 Other National Policies

Additional applicable Government and NHS documents have been included Appendix 1.

2.1.2 Aligning with local/regional strategic priorities

2.1.2.1 Bedford, Luton, Milton Keynes Integrated Care System (BMLK ICS)

BCCG oversee the three Kempston surgeries in the Caritas PCN. In turn, it has recently joined the

BLMK ICS which also includes the local councils and CCGs for Luton, Milton Keynes and Central

Bedfordshire. The ICS has set out the following objectives:

i Illness prevention and health promotion - Preventing ill health and promoting good health

by giving people the knowledge and ability, individually and through local communities, to

manage their own health effectively.

ii Primary, community and social care - Delivering high quality and resilient primary,

community and social care services across Bedfordshire, Luton and Milton Keynes.




iii Secondary care - Delivering high quality and sustainable secondary (hospital) care services

across Bedfordshire, Luton and Milton Keynes.

iv Digital programme - Design and deliver a digital programme, maximising the use of

information technology to support the delivery of care and services in the community and in

primary and secondary care.

v Demand management and commissioning – Making the right services are available in the

right place, at the right time for everyone using health and social care in Bedfordshire, Luton

and Milton Keynes.

The proposed health care Hub in Kempston will fulfil these objectives through the

provision of a more robust and expanded primary care service that is able to address

more of people’s needs without referral to hospital and tackling problem at an early

stage, near their home, before they are able to develop into more complex medical

conditions requiring secondary care intervention.

2.1.2.2 Bedfordshire CCG draft ‘Straw Man’ Clinical Model

In addition to operational configuration, there are a number of local strategies that inform the

format of the MCCC. The ‘Straw-man’ Clinical Model provides a draft of a clinical model for the

BLMK Hub Programme. The Model has been developed by a small group of clinicians, professionals

and managers across the system in Bedfordshire. The model indicates the range of services which

might be offered from a Hub based on the size of the population served and provides flexibility for

each location to be tailored to the needs of local population.

The relevant extract from the Clinical Model is show the following:

Service Line Neighbourhood Hubs - (30k+ population)

Unscheduled Care Minor illness and minor injury

Near-patient testing (NPT)

Pharmacy Dispensary

8:00-20:00 weekdays, plus some weekend provision

GMS Urgent Care from practices based in Hub / shared same day

access service across practices, plus extended access

Prevention/ early

intervention

Services

Lifestyle services, e.g. smoking cessation, weight loss

Voluntary services

Maternity Antenatal care

Post-natal community care

Other IM&T interoperability to allow Hub clinicians to view diagnostic

results/imaging

Commercial and community facilities

Enhanced Primary

Care

Core primary care – potential to be delivered at scale

Proactive management of long term conditions (LTCs)

Near-patient testing and phlebotomy

Care navigation/ health coaching/ social prescribing

Medical care/complex care support for care homes




Group education (e.g. DESMOND, DAPHNE)

MDT risk stratification & case management

Comprehensive Geriatric Assessments

Community clinics – e.g. wound care/tissue viability, podiatry,

continence

Base for adult community nursing team

Base for 0-19 team

Base for social care practitioners

Primary care mental health workers

Psychological support for people with LTCs

Table 2 - Extract form Bedfordshire CCG's Straw Man Strategy

2.1.2.3 Bedford Borough - Health & Care Estate Infrastructure Framework

The identification of Kempston as a suitable location for a Hub has been widely considered by the

Council and CCG, but it was formally set out as a in the Health & Care Estate Infrastructure

Framework document, in which it identified that an under provision of primary care services in

Kempston could be resolved through the development of a MCCC (aka. Hub).

The document proposes consolidation of the Caritas Medical PCN onto 4 locations. Shortstown,

Wootton and Queens Park would remain in their current location. Meanwhile Cater Street, King

Street and St Johns surgeries would co-locate onto a new site to serve Kempston. The new facility

would be sized to meet the immediate lack of space experienced by all surgeries and ensure that

the area’s significant house building plans could also be accommodated in a single location. Making

use of the expanded range of services being provided form Kempston, Wootton would act as a

spoke, utilising the services of the Hub to supplement its existing service offer to patients.

In addition to addressing the lack of space, bringing the practices closer together physically, as well

as administratively through the PCN improves the robustness of Primary Care services for the

whole of Bedford. As two of the practices have one or two partners, failure of one practice,

combined with the current space shortfall would mean the other practices would be unable to

expand to meet the displaced patients.

2.1.3 Existing service configuration

The three Kempston Surgeries are all well-established organisationally and within the community.

They all provide similar services, with the two key exceptions being Cater Street which does not

undertake minor operations and King Street with has an onsite pharmacy. King Street is also a

training practice.

All three surgeries are within the same PCN, although this is yet to launch. There are three other

surgeries within the PCN, however these are outside of Kempston. However, of these three

surgeries, Wootton’s close proximity to Kempston means that it is being considered in conjunction

with Kempston. Whilst it would not relocate from Kempston, it requires a new estate proposal

(covered in its own PID, separately to this SOC) and through its historic ties is interested in

operating as a spoke to the Kempston MCCC. The surgery in Wootton was established circa 15

years ago, prior to which residents of the village registered in Kempston. Creation of the MCCC in

Kempston would allow Wootton residents to make use of out of hospital services which would not

be economically viable to deliver in Wootton.

The PCN has enabled the three Kempston Surgeries to commence jointly commissioning new

services. Notably this includes social prescribers who are partly based in the Cater Street surgery

as it has some capacity, but supports patients from all three surgeries.




2.1.3.1 Impact on existing service configuration

Within all of the surgeries, space has become a major limiting factor in their ability to serve their

registered patients and meet the needs of a modern primary care system requiring significantly

more than the traditional GP consultation rooms.

Surgery NIA of

clinical

space

Patients

/sqm

Projected

patients /sqm

by 2030

Consequence

Cater Street 139 29 32 At 29 patients/sqm the practice is deemed constrained and will suffer

from increased waiting times during peak times.

King Street 345 36 41 Over 29 patients/sqm the practice is severely constrained and will face long waits to see a GP at all times of the year. Its ability to provide

services beyond its GMS contract is very difficult due to the space required.

St Johns 163 38 43 Over 29 patients/sqm the practice is severely constrained and will face

long waits to see a GP at all times of the year. Its ability to provide services beyond its GMS contract is very difficult due to the space

required.

Table 3 - Surgery Information

The lack of rooms for the provision of out of hospital services means that GP consultation rooms

are used for these purposes where possible. Whilst this intensive use of space is beneficial, the lack

of alterative space for GPs to work foreshortens any possible gains. None of the surgeries have

alternative space for GPs to work beyond a consultation room. As a result, consultation rooms have

to be used for telephone call appoints to patients when they could be conducted in more cost

effective back of house space, had space been available.

2.1.4 Local body support

Although addressed separately in this section of the SOC, BBC and BCCG have had an equal role in

the development of the SOC and recognise the need to improve capacity and robustness of the

primary care network in Kempston.

2.1.4.1 Bedford Borough Council (BBC)

The Council has undertaken procurement of this SOC on behalf of BBC and BCCG to unlock OPE

funding. Whilst the council is not responsible for the provision of primary care services, it

recognises that it is an integral component in the range of public services that are provided to the

town and the significance of having a fit for purpose healthcare system. The Project Team

assembled to complete this SOC includes representatives from BBC, include Health, Property and

Planning.

A number of Public Health bodies are expected to locate into the MCCC upon completion. Whilst

their mobile nature of working makes it unlikely they will require back-office space, they have




recognised that the facility will be ideally positioned to provide a central point from which services

can be provided.

Throughout the creation of this SOC the Mayor of Bedford and Chief Executive of the

Borough Council have been directly involved at all stages.

2.1.4.2 Bedfordshire Clinical Commissioning Group (BCCG)

As the organisation responsible for commissioning and managing the GMS contracts in Kempston,

the CCG is intrinsically involved in the creation of this SOC. A number of representatives are

present on the Project Team and they have facilitated engagement with frontline care providers,

including the three GP surgeries and other healthcare stakeholders.

As part of the adoption of this SOC the accountable CCG officer for Kempston MCCC SOC

authorship has presented the completed document to the CCG Board.

2.1.5 Alignment with BBC strategic priorities

BBC has established the Bedford Borough Joint Health and Wellbeing Strategy (2018-2023) with

the vision of facilitating “residents [to be] able to live healthy and independent lives, in

strong and safe communities with easy access to high quality and efficient public

services when they need them.”

The Joint Health and Wellbeing Strategy is informed by the Joint Strategic Needs Assessment of

the health and wellbeing needs of Bedford Borough. It responds to the needs of local residents, but

also acknowledges the ongoing evolution of service delivery whereby BCCG have come together

with other CCGs, namely Luton and Milton Keynes to form a Sustainability and Transformation

Partnership (BLMK STP). The BLMK STP has the ‘triple aim’ of improving health and wellbeing for

residents, improving the quality of health and care services with more joined-up working, and

tackling the financial and workforce challenges faced as a system.

The overarching ambition of the Health and Wellbeing Board remains to improve the health and

wellbeing of residents and reduce health inequalities, and to achieve this a life course approach will

be maintained, that is ensuring plans are targeted at critical points throughout life: giving children

and young people the best start in life, and enabling adults and older people to live well and remain

independent. However, the health of residents and communities is also shaped by the conditions in

which they live, the extent of social connections, and whether they have stable and supportive

work. These are some of the so-called wider determinants of health, and to promote efforts to

tackling the wider determinants of health a third priority has been included: promoting strong, safe

and healthy communities.

Three cross-cutting themes run through the three priorities of the Joint Health and Wellbeing

Strategy:

1. The need to embed prevention and early intervention throughout services, in order to reduce

the burden of ill health and need for costly health and care services.

2. Addressing mental health and ensuring lifelong mental wellbeing and resilience.

3. Tackling health inequalities, targeting resources proportionately towards the most

disadvantaged and be mindful of the likely impacts of plans on the most vulnerable groups.




Whist it is recognised that greater emphasis on prevention may slow growth in demand for health

and care services, it is imperative in the current financial climate that the actions agreed are

delivered within the respective resource envelopes of the partner organisations.

Delivery of a MCCC in Kempston will support the achievement of these aspirations through

improved access to primary care and the co-location of primary health services, reducing demand

on in-hospital services. Whilst GPs will provide mental health support, it is in the intention of the

MCCC to work with additional mental health support organisations who would provide access to

mental health services in the MCCC. Their co-location would ensure a closer alignment of services

tailored to the needs of the individual.

2.1.6 Alignment with BCCG strategic priorities

BCCG has set out a number of strategic priorities:

Objectives Response

Commission high quality, safe and

sustainable models of care that deliver

effective clinical outcomes and patient

experience using evidence based

decisions and best practice.

The existing primary care estate in Kempston

is in need of modernisation to provide buildings

and clinical spaces that meet current day

standards. To ensure that it is sustainable, its

capacity needs to be expanded, to address the

significant increase in service users and the

drive to provide more local healthcare

targeting the causes of poor health. Reducing

the causes of poor health not only leads to a

healthier population, but reduce demand on

secondary and tertiary levels of health care

which are more costly to deliver.

The MCCC follows the proven and documented

approach of delivering a range of primary care

services cooperatively between a range of

healthcare professionals and patients.

Ensure that there is a financially

sustainable and affordable healthcare

system in Bedfordshire.

Elaborated in further detail later in this

document, the MCCC financial models

demonstrates the overall viability of the

proposal.

Engage with both local councils and also

our partners across the wider health

economy working on plans to strengthen

primary care, improve outcomes and

integrate services for the populations we

serve.

Throughout this project the collaborative

approach between the Council and CCG has

supported the development of a viable and

deliverable option.

Support local people and stakeholders to

have an influence on services we

commission to ensure our decisions are

informed and shaped by local views and

insights.

Although the Project Team chose not to consult

with service users at this early stage in the

development of the MCCC, service providers

have been consulted and around 30 different

services are anticipated to be delivered from

the MCCC. In addition, these services will be

provided in a range of spaces including




consultation, treatment and multifunction

rooms with sufficient capacity to meet the

planned and evolutionary needs of service

users.

Govern with transparency, comply with

best practice and meet our statutory

obligations.

This SOC will reviewed internally by the CCG

and its outputs carried forward where

appropriate.

2.1.7 Clinical Strategy and Commissioning Intentions

The proposal seeks to expand the range of services that can be accommodated in primary care

buildings to reduce the need to attend hospital. To achieve this BCCG will continue its trend of

commissioning services outside of the hospital environment. The current estate lacks the space

within surgeries to provide these services whilst continuing to meet requirements of GMS

Contracts. As a result, services have been provided in a range of location and building types

sourced by providers. Such practices are not conducive to overseeing the interconnected needs of

patients, whilst provision of healthcare across a myriad of locations can be confusing and

unreliable.

Explicitly excluding accommodation payments from future commissioned services and replacing

with a stipulated location would be an effective way to consolidate services towards the MCCC. This

would require further development and financial modelling at an OBC stage ascertain how the

finances would operate for recharging of space. For their part, services contacted as part of this

SOC were positive to idea of collocating with GPs where they didn’t already. Those that already

provided services from a surgery setting were keen to maintain and expand the arrangement, but

were prevented by the estate. They also felt it increased the quality of the service provided.

2.1.8 Promoting integrated working between health, social care and public health

2.1.8.1 Integrated working

A number of services, including social prescribing are currently provided from the existing surgery

estate. However, in the case of social prescribing, it can only be provided from Cater Street

Surgery as the other surgeries lack the space to accommodate the service. The service was highly

complementary of the opportunity to provide services from the Cater Street surgery, although as it

is the smallest of the three surgeries, opportunities for interactions between other healthcare

professionals within the PCN were limited and expanding the reach of this service was curtailed by

the estate. All services contacted in the preparation of this SOC were supportive of opportunities to

work closer with GPs.

As part of a separate proposal, discussions were held with Wootton Vale Healthy Living Centre

regarding the re-provision of their current building. They Wootton surgery is part of the same PCN

and has been working increasingly closer with the other Kempston surgeries in identifying how they

could work with a higher degree of integration.

2.1.8.2 Improved access

Expanding access to the GMS elements of the building services is limited by the contractual

constraints of the contract which provide a limited number of hours. However, it is envisaged that

other services could easily expand and in the building model, have been calculated over a 12-hour

day (0800 – 2000hrs), including some weekend access has the building open for 66 hours per

week. Currently, the estate operates from 0800hrs to 1830hrs 5 days a week with one surgery




open every other Saturday morning and as a result the new MCCC will be operational for an

additional 13 hours per week.

As expansion of the GMS contract is limited, it is envisaged that activity in the evenings will focus

on Extended Hours, Extended Access and those services delivered by visiting healthcare

professionals.

The NHS aspiration for 7-day services is possible, but currently there is no aspiration within the

PCN partner to offer this service. The two smaller surgeries have limited numbers of existing staff

and a move towards 7-day service would only be possible through additional recruitment. The CCG

is actively engaged with these surgeries specifically around transitioning them towards a more

robust service delivery model. Once complete, it will be possible to investigate increasing the

number of operational days.

The role of the SOC is to test the overall viability of the proposal and it is not within the remit of

this document to drive changes in how surgeries should be managed. However, it does note that

increasing service provision across a 7-day working week would allow the proposed MCCC to

operate more intensively and therefore be smaller and therefore cost less to deliver.

The current primary care estate within Kempston is comprised of three sites spread throughout the

town. Provision of a single site will inevitably reduce the accessibility of services to those who live

adjacent to the existing surgeries. However, it should be noted that older surgeries, such as in

Kempston, where often sited where land or buildings permitted and the robust processes that is

being enacted as part of this SOC were often not undertaken historically, or if they were, urban

areas have often evolved to such an extent that the original considerations are now obsolete. Later

sections of this document expand upon this point, quantifying impact of accessibility and ultimately

concludes that some patients within a 15-minute walking radius of Cater and St John would be

disadvantaged, however anyone traveling by public or private transport will be unaffected or

benefit from increased accessibility.

2.1.8.3 Strong public and patient engagement

The Project Team, including the CCG felt it would be inappropriate to consult with patients or

patient representative bodies at such an early stage in the process whilst there remains a

significant number of variables and uncertainties. The Team agreed that it would only be

appropriate to talk with these stakeholders from the OBC onwards.

However, all parties have been mindful of the impact on patients any major change to the existing

surgery structure of Kempston. Key factors such as relocation distances service provision have

been studied in detail.

2.1.8.4 Consistency with current and prospective need for patient choice

Development of a new MCCC in Kempston will alleviate the current constraints on the primary care

estate that by enlarge prevent patients being offered a choice over their primary care. Shortfalls in

the current estate mean that there are rolling closures of patient lists which prevent patients

choosing which of the three Kempston surgeries they wish to register with. In addition, the under-

provision of space within each surgery curtails the number of appointments each surgery is able to

offer despite maximising the potential of the GMS contract. As a result, there are perpetual waiting

times to get a GP appointment which substantially worsen during peak times. These restrictions on

the primary care estate increase the risk of patients presenting themselves at A&E or walk-in

centres, butting strain across the entire healthcare network.




2.1.8.5 Clear, clinical evidence base

The building model developed as part of this SOC are based on HBN11.01 guidance for the

calculation of consultation and treatment rooms. The process calculates the number of

appointments per annum needed to satisfy the needs of the patients and calculates the number of

appropriate rooms needed to meet these needs. Room sizes are also based on HBN guidance.

The guidance does not provide a method for calculating the quantity of rooms needed to deliver the

other services identified in this SOC. However, the same process has been applied by calculating

the number of hours each service will be provided for from the building and ascertaining the

appropriate number of rooms needed to fulfil this need.

As part of the OBC this will needed to be further developed and a ‘timetable’ developed showing

hour-to-hour how each room is envisaged to be used. The OBC will also allow for percentages to be

converted to fixed dimensions, specifically Circulation, Engineering and Planning spaces.

2.1.8.6 Support for proposals from commissioners

Bedfordshire CCG has been heavily involved throughout the development of this SOC. This has

included attending all team meetings and being present during meetings with stakeholders. The

CCG has also reviewed the content of this document at an officer and Board level.

Location

2.2.1 Geography

Kempston is town located on the edge of Bedford, within Bedfordshire. Neighbouring major

developments include Milton Keynes and Luton.

Figure 2 – Bedfordshire location plan




Although a settlement in its own right, its expansion and that of Bedford have merged into a small

conurbation. Despite this Kempston retains its own identity, in part helped by the railway line

which has only a few crossing points and runs on the boundary of the two settlements to the East

of Kempston. Meanwhile to its north Kempston is separated from Bedford by the River Great Ouse.

The southern and western boundaries of the town are typical urban fringe and merge into open

farmland. In recent years this edge has been pushed out through new housing developments.

Given the housing pressures in the area and absence of any other immediate settlements, it is

likely that the southern and western boundaries of Kempston will continue to press outwards as

more housing is built.

Figure 3 – Kempston location plan

Kempston is comprised of the following Wards: Kempston North; Kempston Central and East;

Kempston South; and Kempston West. The population is around 22,000 residents although more

from the surrounding rural areas make use of the shops and services within the town. Over the

coming years it is likely that this number will increase by around 7,000 additional residents as a

result of new housing. Most of this expansion will be in Kempston South and Kempston West

wards.




Figure 4 - Kempston Wards

2.2.2 Key urban characteristics

The main arterial route through Kempston is Bedford Road, on which the majority of shops and

services are situated. The town has a ‘high street’ arrangement rather than a defined urban core

with shops and services spread along the road. However, the Saxon Centre complex, which

includes a Sainsbury’s, is regarded by most residents as the town’s centre despite it having few

other services other than a large underground car park.

As urban development continues in the south and west of the town, its epicentre will start to follow

and migrate. However, the lack of any retail properties at the western end of Bedford Road will

curtail this effect by in large.

Bedford Road acts as a collector for most of the town’s traffic. Most roads lead onto Bedford Road

and as a result a large number of bus routes pass along it and it can become congested with

private traffic during peak times. Bus lanes help to keep public transport flowing.

Kempston North

Kempston West

Kempston South

Kempston Central and East




Equality and Diversity

The proposal will support the advancement of equality and diversity through significant

improvements to the physical estate. Two of the three current buildings are unable to

accommodate patients with impaired mobility throughout the building, who are limited to the

ground floor only. In addition, the buildings have restricted internal corridors and communal areas.

Access has been improved to align with legislation and the Public Sector Equality Duties, however it

is often through retrofit, rather than implicit within the design. Development of a new MCCC will

enable barriers to access to be designed out and the building supported by a lift allowing access to

all areas of the building for health workers and patients.

Healthcare activity demand and capacity projections

2.4.1 Population change

Bedford Borough is home to around 171,625 people, a figure that has grown significantly in recent

years due to large scale housing development. This picture is being replicated throughout the

Cambridge – Milton Keynes – Oxford Corridor.

Despite the current geopolitical uncertainty, housing demand is likely to persist and this can be

seen in the new housing sites that are coming on line and the maintenance of housing land value.

Much of the population change will come from new housing development, as unlike some other

locations, there are few sites which could be converted into residential. In addition, there are only

a few small brownfield sites within Bedford. The combined effect of this will be to push housing

development to the peripheral locations of Bedford. This includes Kempston which sit to the south

of Bedford. Although the two settlements abut on the northern and eastern flanks, Kempston has

farmland to the south and west which are identified for development.

In addition, the settlements to the south, such as Wootton and Stewartby are likely to expand.

Their current size is insufficient to support many services of their own and whilst this might change

over time, initially residents of these settlements will use Kempston and Bedford for retail,

employment and accessing services.

The Caritas Medical PCN has a patient list size of 43,972. Of the surgeries in Kempston, they have

a combined list size of 22,743 patients. This is anticipated to increase significantly as new housing

comes on line in the contractual catchment areas of the PCN.

2.4.1.1 Projected housing change

Planning permission has been sought or granted for a number of new major housing developments

planned within the existing catchment areas of the three Kempston GP surgeries:

Up to 2023 1481 new homes

Up to 2027 2040 new homes

Up to 2035 3040 new homes.

The 3040 new homes that will be built within the Kempston Surgery catchment area are expected

to increase the population by 7298 individuals based on Bedford Borough Council’s standard of 2.4

residents per home.

A breakdown of the sites identified have been included in Figure 5.




Whilst other development sites are active across Bedfordshire, they have been excluded as they fall

beyond the contractual catchment area of the three existing GP surgeries in Kempston and those

populations will be serviced by other primary care services within Bedford CCG.

However, there are two large areas of land that are expected to be identified for housing with a

combined estimated area of 14 acres over the next 2-3 years. Housing densities typically exceed

30 properties per acre for urban areas. If this is developed it would bring an additional 1,000

residents to Kempston. As this is speculative and has not received planning this has not been

included in this report.

2.4.2 Demographic change

As with the majority of the UK, the population in Bedford and Kempston expected to live longer

whilst birth rates will remain relatively static. By 2041 the number of patients over 75 years old will

have increased by 50% and the number of patients over 85 will have virtually doubled. In Table 4

the current population is shown with the bars with the predicted population shown in the lines.

Whilst the number of pre-retirement aged patients is expected to remain unchanged.

Under the age of 60, the 2016 and 2041 populations are very similar, confirming that birth rates

will remain constant. After the age of 60 the trends diverge with significantly more over 60 year

olds in the population by 2041.

A larger number of older people in the community will create different demands on the health

services. One factor will be an increased demand on managing health conditions associated with

older age, namely mobility and cognitive function. Many of these conditions can be effectively

treated in the community if support is available.

Table 4 – Bedford Borough projected age demographic

As identified in the services to be provided form the MCCC, the new building provides a significant

amount of space for services that are able to assist in the management of long-term health issues

at a community level.

1500

1000

500

0

500

1000

1500

Popula

tion s

ize

Age in years from 1 to 89+

Bedford Borough Age Demographic

Females 2016 Males 2016 Males 2041 Females 2041




2.4.3 Capacity

The size of the three Kempston surgeries is set out in the table below. It provides the net internal

area of each surgery and excludes ancillary space such as training room and pharmacies.

Exclusions of these facilities aligns the space calculation with the NHS England Space Maxima

Schedule to allow a standardised comparison of the three surgeries against the expected clinical

space the NHS sets as being needed to treat the patient list size.

Surgery Patient list NIA (excl ancillary space) Patients/sqm1

Cater Street 4,029 139 29

King Street 12,287 345 36

St Johns 6,247 164 38

Table 5 – Existing surgery space standards

The Maxima schedule considers any surgery with a patient/sqm ratio of more than 29 patients/sqm

to be constrained.

As can be seen, none of the surgeries have room for expansion of their patient list. St Johns has

closed its list to new patients due to the lack of clinical space it has available. King Street remains

oversubscribed how due to a lack of alternatives it is required to keep accepting new patients.

Further increases in population will exasperate the situation.

Over the next 15 years it is expected that 583 additional people will register with the Kempston

surgeries. This figure has been jointly agreed by the Project Team which includes representatives

from the CCG and Local Authority who have verified these figures on behalf of the project. Using

the Maxima estimator, this would need an additional 32sqm of clinical space to meet demand.

However, this would be in addition to the current shortfall of 762sqm already missing from

Kempston.

Space requirements

2.5.1 Department for Health Guidance

The Premises Maxima Size Schedule recommends 16 patients per sqm and has been robustly

tested nationally, forming the basis for sizing GP surgeries for a number of years. The following

equation sets out how the maxima can be calculated and uses the example of Cater Street from

Table 5 above.

𝑃𝑎𝑡𝑖𝑒𝑛𝑡 𝑙𝑖𝑠𝑡 𝑠𝑖𝑧𝑒 𝑜𝑓 𝑝𝑟𝑎𝑐𝑡𝑖𝑐𝑒

𝑁𝑒𝑡 𝐼𝑛𝑡𝑒𝑟𝑛𝑎𝑙 𝐴𝑟𝑒𝑎 𝑜𝑓 𝑝𝑟𝑎𝑐𝑡𝑖𝑐𝑒=

𝑃𝑎𝑡𝑖𝑒𝑛𝑡𝑠

𝑠𝑞𝑚 𝑒𝑔. 𝐶𝑎𝑡𝑒𝑟 𝑆𝑡𝑟𝑒𝑒𝑡 =

4,029

139= 29

Through PCNs and the expansion of primary care services there is some concern that moving

forward this space allocation would be insufficient to house the additional services.

BCCG adopt the same space guidance when calculating GP rent reimbursement for GP surgeries of

16 patients per sqm. However, HBN guidance is generally silent around how space for PCN’s should

be calculated.

1 Patients/sqm is based on the BCCG’s calculation for surgery and the NHS England Space Maxima Schedule of 16 patients per sqm.




2.5.2 Engagement feedback on capacity requirements

As part of the preparation of this SOC, meetings were held with each GP practice. The availability

of space was discussed and in general reported as insufficient for the needs of each surgery.

Part of these discussions including the list of PCN services that are currently undertaken at the

surgery. Further discussions were held directly with PCN partners who highlighted that provision of

their services within a GP surgery environment would help provide a more integrated approach to

care and improve patient treatment.

Both GP and healthcare partners detailed the services that are currently provided within the PCN

and the number of hours per week that are needed to deliver these services. This allowed the

project to build up a specification for how much space would be needed to consolidate PCN services

within the proposed building.

Room sizes were led by guidance from HNB11.01.

The total space allocation was then verified by the Project Team.

2.5.3 Agreed size and scope

In total, the Project Team and its stakeholders developed and agreed the following requirement as

being sufficient to meet the combined needs of the three practices and a proportion of the PCN

services. It was noted that this proposal covers 3 of 6 surgeries within the Caritas PCN, it is

expected that some PCN services would continue to be provided at the other surgeries not included

in this study.

Key requirements:

Total expected patient list 23,326

Anticipated total annual contacts 121,344

Consultation rooms required 18

Treatment rooms required 4

Multifunction rooms used by PCN stakeholders 13

Car parking spaces 105.

Notably, the recommended number of consultation rooms has remained the same and the number

of treatment rooms has been reduced. However, those rooms intended to be used by the PCN is

proposed to be increased from 3 to 18, indicating the significant strain that implementation of the

PCN will have on the existing estate should investment not take place. Those rooms intended to be

used for PCN services are envisaged to be of a less specialised fit out than consultation or

treatment rooms. This is possible and many of the PCN services support mental health, and

preventative services that do not need to be provided in a clinical environment.

From discussions with GPs, they are currently facilitating PCN services by using existing GP

consultation rooms. This, however, prevents the space from being used by GP to undertake

consultations. The proposed mix of consultation, treatment and PCN space reflects an up-to-date

special requirement for Kempston where rooms are used in the most efficient purpose and




Rationale and Objectives

2.6.1 Rationale for Scheme

The proposed MCCC will improve access and the quality of primary health by expanding the areas

capacity and joining up a number of primary care providers currently working in a range of un-

coordinated locations around the Kempston area. The following table provides a number of specific

objectives the MCCC will need to fulfil and how these could be assessed through the OBC, FBC and

following completion.

Specific

objective

Measurable Achievable Relevant Time-bound

To provide the estate with

capacity and improved capabilities

Increasing the number of

available appointments through expansion of the building and compliance with the HBN

guidance on space

Delivery of a new MCCC would

enable the delivery of this objective.

The MCCC will significantly

improve access to primary care services in line with the STP’s and NHS’s objectives of providing more

care in the community and reducing attendance at hospital

Delivery of the MCCC is possible

in year 2023/24, having allowed for completion of the OBC and FBC, land assembly and development of

the proposed building.

To develop and

implement a mutually-supportive network of GP practices

Number of PCN

surgeries accessing out of hospital services.

Delivery of the

MCCC would co-locate a large number of healthcare practitioners,

facilitating informal interactions and increasing referral.

Referral to out of

hospital services addresses illness and the cause of illness at an early stage preventing

it from developing into conditions that require hospital and inpatient services.

1 year following

completion of MCCC.

Illness prevention and health promotion

Reduction in the need to attend hospital of in-patient services

Giving people the knowledge and ability, individually and through local

communities, to manage their own health effectively.

Preventing ill health and promoting good health by

1 year following completion of MCCC.

Primary, community and social care

Reduction in A&E attendance

Delivering high quality and resilient primary, community and social care

Treating ailments in a primary care setting is more cost effective than in hospitals and prevents

1 year following completion of MCCC.




Specific

objective

Measurable Achievable Relevant Time-bound

services across Bedfordshire

conditions developing to the point where in hospital treatment is

required.

Secondary Care Reduction in inappropriate

A&E attendance

Providing a larger primary care

base allow more

patients with a wider range of ailments receive treatment in their community without needing to attend hospital

Treating ailments in a primary care

setting is more

cost effective than in hospitals and prevents conditions developing to the point where in hospital

treatment is required.

1 year following completion of

MCCC.

Table 6 – SMART objectives

2.6.2 Stakeholder Engagement

2.6.2.1 Defining Stakeholders

Ensuring a robust engagement process is imperative in ensuring that the SOC mirrors the needs of

the local community and its health practitioners. Stakeholder engagement must be timed and

coordinated with the progress of the project to ensure that it can provide meaningful input and

help guide the process. A full list of stakeholders has been included in Appendix 2.

Stakeholders were initially identified by the Project Team, with a second round of stakeholder

identification taking place following the GP meetings. Stakeholders were identified as individuals or

organisations that would be central to the MCCC’s ability to provide primary care services to the

local community and meetings were held with each stakeholder.

The Project Team elected to exclude some organisations, such as charitable bodies as they were

felt to be unable to provide any commitment at this stage in the process and their service

provisions, whilst desirable, were not essential, with many able to provide their services through

the hiring of multifunctional space.

Future OBC and FBC should endeavour to include voluntary organisations as well as reconfirming

the requirements of those stakeholders consulted in the production of the SOC.

2.6.2.2 Stakeholder consultation details: GPs

GPs play a pivotal role in coordination patient’s use of primary care services. For this reason, they

were the first group of stakeholders to be consulted. Consultation took the form of interviews held

over three days in August 2019. The interviews used a set agenda, previously approved by the

Project Team to identify the current physical condition of the surgery building, its operations, future

aspirations of both, together with identifying how a future hub could improve the operations of the

practice.




Following the interviews, notes from the meeting, approved by those present, were circulated to

the Project Team and have been included in Appendix 3 for reference.

In parallel, meetings were also held with the PCN representative for the Caritas PCN of which all

the surgeries are part of. The PCN representative was involved in the site selection process in

which the preferred site was identified.

Additionally, GPs and the PCN were consulted on the services that would be delivered from the new

facility and the expanded PCN services envisaged for the future.

Key findings from these discussions identified that the estate was a major restriction on the

provision of health services and the robustness of primary care in the area. The inability to expand

any of the surgeries in the area limits the extent to which the number of an appointments can be

expanded to meet the needs of the growing population. In addition, it also prevents new services

being delivered as part of the expansion of primary care and out of hospital services envisaged for

the PCNs.

The constraints of the estate also deter new GPs from joining the PCN at all levels. This increases

the risk around the legacy planning for the surgeries. Whilst this issue is not unique to Kempston,

the culmination of the other factors significantly increases the impact of this risk and limit the

PCN’s ability to implement mitigations.

The GPs will continue to play a central role in the development of the future OBC and FBC.

2.6.2.3 Stakeholder consultation details: other organisations

A range of other healthcare services and providers have been consulted as part of the preparation

of this SOC. Those consulted includes:

East London Foundation Trust (ELFT)

Circle Integrated Care

East of England Ambulance Service

Bedfordshire Hospitals

Bedfordshire Rural Communities

Charity Children Services

Cambridgeshire Community services

Bedfordshire Police.

Through these consultations, around 25 different services were identified that could be located

from the MCCC in Kempston. An overarching theme to the consultation was the pre-existence of

each organisation’s own estate strategy. As a result, no organisation expressed an interest in

basing staff from the MCCC on a permanent basis. Organisations tended to operate with well-

established mobile working policies and practises. However, many required space from which their

services could be provided and reach service users. Common requirements were for multi-

functional rooms from which individual or group work sessions could be held.

More specific requirements included multi-function rooms with an external door to enable their

services users to enter/exit directly without having to go into the surgery. Also, facilities for making

teas and coffees was useful. The option to store materials was also beneficial.

Over the course of the interviews none of the organisations expressed an interest in relocating

static equipment into the MCCC, citing relocation cost as the primary deterrent.




As part of the building model the likely number of hours these services would use the building for

were calculated. However, in the OBC it will be beneficial to timetable these out to ensure

utilisation of the rooms remains efficient.

2.6.2.4 Stakeholder consultation details: Local Authority

BBC were able to commission this report after securing OPE funding for its authorship on behalf of

their partnership with BCCG. BBC fully understand the importance of developing a robust network

of primary care services to support the existing and expanding population of Kempston.

Within BBC, this project has been over seen by the Senior Officer and Policy Advisor for Health.

Senior and Elected individuals support

Additionally, the Chief Executive of the Council and the elected mayor have both been regularly

updated throughout the development of this report and fully support its findings.

Both individuals were consulted following the initial identification of the potential sites. They

reviewed all 15 potential sites and fully supported the Project Team in their evaluation of this list of

sites to arrive at the preferred option. Following the identification of the preferred site the Chief

Executive and the Mayor reviewed the financial model and supported the overall findings of the

report.

Local councillors from each of the 3 Wards that make up Kempston have also been directly

involved throughout the process. They have personally reviewed the findings of the report as they

have been developed and support its overall findings. The local Councillors recognise the

importance of improving the robustness of the Primary Care Network in Kempston by ensuring that

patients have access to an appropriate number of GP appointments and that overall health and

wellbeing of the community is enhanced through additional services that will be provided in the

new facility.

Other Local Authority Departments

A number of other Local Authority departments have been involved in the preparation of this SOC.

Notably these include Property Services and Public Health. Property Service’s role has been in

supporting the development of the estate proposal, and identifying surplus land within the public

sector.

Public Health have been consulted as stakeholders with an interest in providing service from the

completed building. Whilst their own workplace strategy is centred on mobile working, they

consider the new MCCC to be a central hub for the delivery of their services to the Kempston

community. As a result, their requirements have been included in the space calculation.

Both departments should continue to be involved throughout the subsequent OBC and FBC. This

will allow them to continue to inform on property requirements within the MCCC.

2.6.2.5 Stakeholder Engagement Summary

Overall, all stakeholders were keen to be involved in the project as it continues to develop and

would like to operate services from the facility. As stakeholders currently have existing back-of-

house estate strategies in place, none were seeking office accommodation. Additionally, the nature

of the work and the manner in which it is procured meant none were interested in take a lease of

space within the MCCC, but would like to have access to space within the building to run

surgeries/clinics, rent/booking space as required.




As a result, it is recommended that all stakeholders continue to be engaged throughout the

development of the OBC and FBC.

Risk

The emerging nature of the PCN initiative and the infancy of this proposal present a number of

generic risks that would be expected at a SOC stage. These are:

National and local strategic priorities continue to develop and change

How PCNs will operate is only now beginning to be tested and there are few examples of

best practice

HBN Guidance documents which have guided the primary healthcare estate have not been

updated to respond to the new estate requirements of PCNs and their extended range of out

of hospital services

Stakeholders, whilst consulted as part of the SOC, have not made any firm commitments

Funding initiatives needed to deliver this project are not yet announced at the time of

writing

Viability of the overall scheme may change due to economic forces as the future Outline and

Full Business Cases are written.

The production of the OBC and FBC will go some way to removing a number of these generic risks

as well the project specific risks identified in the next section.

A risk register of the associated risks of the project has been included in Appendix 4.

2.7.1 Conclusion

The expected outcomes and benefits, as well as the mains risks, key project constraints

and dependencies from this scheme have been identified, developed and agreed by the

Project Team during the development of this SOC. They have been assessed against

national, regional and local healthcare policies to ensure they align with current key

objectives.

These have been combined with following Economic Case to set out the details of how a

solution can be provided for health care challenges currently faced in Kempston within

the wider framework of the STP and NHS.




3 Economic Case

Introduction

The purpose of the economic case is to identify and appraise the options for the delivery of the

MCCC and to recommend the option that is most likely to offer best value for money. The first

stage of the economic case explores the preferred way forward by undertaking the following

actions:

Reviewing population changes and confirming need

Develop and evaluate the long list of options

Recommend a preferred way forward in the form of a shortlist of options.

The economic case explains how this is achieved by, identifying and appraising a wide range of

realistic and achievable options, known as the “long list and assessing each site against key criteria

to identify those sites that are deliverable and economically viable.

The shortlist was evaluated by undertaking both a qualitative analysis using the benefit criteria

derived from the SIO and a quantitative analysis which involved applying a Discounted Cash-Flow

(DCF) technique. The qualitative analysis involved participation by the Project Team to ensure

objectivity in the process.

The quantitative analysis of the shortlisted options was undertaken on the basis of the HMT’s

“Appraisal and Evaluation in Central Government” rules and supplementary guidance which are

mandatory for investment appraisal in the public sector. It should be noted that affordability is

considered separately in the Financial Case of this Business Case.

Locations

3.2.1 Potential location

An initial search of the area revealed 15 undeveloped sites within Kempston. Peripheral sites on

undeveloped land beyond the edge of the urban area were not considered as they were felt to be

too remote, lack public transport and would be detrimental to the environment.

All vacant sites within the 4 Kempston wards were included on the site. As the MCCC is evolved

and refined through the SOC to FBC, the building may increase or decrease. Highlighting all

potential sites will assist the OBC and FBC in validating the site selected still remains the most

appropriate. In addition, it will provide future Project Teams with a full rationale of why certain

sites where not favoured during the SOC.

Other key factors that were used to identify potential sites included:

Size – is the site foreseeably able to accommodate a building and car park

Surplus to requirements – is the site vacant, undeveloped, due to be vacated in the

foreseeable future?

Certainty of acquisition – is it foreseeable that the site could be acquired from the

existing owner, or is the existing owner already associated with the project (e.g., local

authority or public sector body)?

Location and access – is the site in or around Kempston and is it foreseeable that the site

could be accessed by car and/or on foot?




The 15 shortlisted sites are shown in Figure 5 together with the existing locations of the three

Kempston GP surgeries.

Site 1 Moorings Site 10 80 Bunyan Road

Site 2 Beatrice Street Site 8 & 9 Land adj BT Offices and Offices

Site 3 Land adj. Kempston Pool Site 11 Land next to pumping station

Site 4 Addison Howard Park Site 12 Kempston Ambulance Station

Site 5 Kempston Police Station Site 13 Land next to Baliol Primary School

Site 6 Saxon Centre Site 14 Land next to Challenger Academy

Site 7 Robert Bruce School Site 15 Bedfordshire Police HQ

Figure 5 – Map of all identified development sites in Kempston

3.2.2 Site Selection - the process

The process to select a preferred site was agreed by the Project Team and focused on a qualitative

assessment of all potential sites in Kempston. A total of 15 sites were identified.

An assessment criterion was developed with the Project Team to assess each site. It focused on

four key themes: Access, Impact, Functionality and Deliverability. These four themes comprised 22

points of measures.




Each of the 22 measures were individually weighted based on how important the Project Team

believed them to be in ensuring the overall deliverability of the scheme. Those measures which

were felt to be essential to deliverability were awarded a higher weighting. The weighted maximum

score was 390 points. Evaluation of each site was based on a scale of 1 to 5:

5 – Meets or fulfils expectations, going substantially beyond expectations

3 - Meets or fulfils expectations

1 - Falls substantially short of expectations, objective still achievable, but with notable

compromises.

A full explanation of the marking criteria is given in Appendix 5.

A score of 0 was also available should a site fail to meet a basic level of the measure. The Project

Team agreed that any site scoring 0 for any measure would be removed from further

consideration. Of the 15 identified sites, 8 received a 0 on one or more measures and were

discounted from further consideration. Commonly this was for measures such as being unable to

form a junction with the highway or the site being too small for the proposed building and

associated car park.

The remaining sites scored between 74% and 39%.

Ranking Score Site

1 74% Site 5 Kempston Police Station

2 47% Site 7 Robert Bruce School

3 44% Site 3 Land adjacent Kempston Pool

4 42% Site 2 Beatrice Street

5 41% Site 14 Land next to Challenger Academy

6 39% Site 1 Moorings

7 0% Site 12 Kempston Ambulance Station

8 0% Site 10 80 Bunyan Road

9 0% Site 4 Addison Howard Park

10 0% Site 6 Saxon Centre

11 0% Site 8&9 Land adjacent BT Offices and Offices

12 0% Site 11 Land next to pumping station

13 0% Site 13 Land next to Baliol Primary School

14 0% Site 15 Bedfordshire Police HQ

Table 7 – Site selection results




Kempston Police Station scored the best during the assessment process and has been selected as

the preferred location for the new MCCC.

The Robert Bruce site, whilst suitable for the development, would need to be brought forward as

part of a masterplan for the site and adopted by the current site owner. Whilst this remains

possible, there are a number of substantial obstacles in the delivery process that would need to be

overcome. Primarily the scheme would need to be adopted by the Challenger Multi Academy Trust,

which for which the provision of health services would sit outside its organisational mandate.

Inclusion of obligations towards the whole landed needed for the MCCC at a planning stage would

be excessive given the size of the Trust’s masterplan proposal.

3.2.2.1 Discounted sites – Existing

The project first assessed the existing sites and the ability to be restructured through management

and procedure changes to meet the demand. Through interviews held with each surgery and

numerical assessments on the space needed to support the Kempston population it was identified

that the estate was already being used very heavily and that additional clinical space was required,

as shown in Table 5 on page 22.

Internal reorganisation, where possible, had already been undertaken with the surgeries converting

back office space into clinical rooms and utilising hot-desking and working from home some years

ago.

Even after maximising the amount of clinical space, the surgeries were unable to provide enough

clinical space.

Expanded the existing surgeries was then reviewed as a means of meeting the clinical space

deficit. However, this had by in large been undertaken with all surgeries having been expanded in

the last 20 years through the use of permanent or temporary buildings. These extensions now filled

the curtilage of each site, significantly compromising parking provisions and leaving no future room

for expansion.

Further expansion beyond the curtilage of each surgery was not possible at a level needed to meet

the space requirements of the MCCC as each location would have required the purchase of multiple

adjacent plots of land with the high probability that each landowner would hold their site in

ransom, thus exposing the project to a significant risk of pay substantially more than the market

rate for the land and ultimately undermining the economic viability of delivery.

All existing sites where therefore discounted.

3.2.2.2 Discounted sites – Newly identified

In identifying new sites, the Project Team used a number of guiding principles to help in the

identification process:

The site should be in its respective settlement of Kempston or Wootton to avoid increasing

travel requirements of patients.

Whilst BBC or public body ownership of the site is preferable, it is not essential.

Empty sites are preferable, although developed sites with a use that could foreseeably be

relocated are considered.

The buildings will be subject to the normal planning and legal constraints and scrutiny.

Therefore, public parks or protected open space has not been considered.




The size of the building is still being considered; however, it will need to be substantially

bigger than the existing facilities in Kempston.

Although the criteria for assessing the sites were weighted to reflect each criteria’s importance, all

assessment criteria were deemed to be important. Therefore, any site where the Project Team felt

they could not award any marks for the site, was discounted.

In total six sites had significant failings these were:

1 Addison Howard Park

2 Saxon Centre

3 Land adjacent to BT Offices and

Offices

4 Land next to pumping station

5 Land next to Baliol Primary School

6 Bedfordshire Police HQ.

Common reasons for the site being discounted was an inability to acquire ownership or establish

access to the public highway or public transport. Full details of can be found in the appended

report.

3.2.2.3 Potential sites

The remaining sites where then assessed based on the agreed criteria. Of these, the following sites

were identified as the most suitable:

Kempston Police Station

Kempston Ambulance Station

80 Bunyan Road

Robert Bruce School (formerly).

Key features that made these sites preferable was their proximity to the centre of Kempston and

public transport, public or third sector ownership and certainty of acquisition. Of the shortlisted

four sites above, Kempston Police Station was identified as the preferred option. Key features in

identifying this as the preferred option were:

Size – The site is able to accommodate the building and associated car park

Surplus to requirements – Although the building is still operational, Bedfordshire Police

force has already identified the site as outside of their estate requirements and has begun a

project to decommission the site. Consultation with the police estates department identifies

that they intend to release the site in Q1 2022. Given the time needed to progress this

proposal through OBC and FBC, it is felt that the projects would align.

Certainty of acquisition – Under the One Public Estate, the Police are required to offer the

site up to other public bodies before it can be disposed on the open market. As a result of

the timescales mentioned previously, this project would be sufficiently mature that by 2022

it could acquire the site for the MCCC.

Location and access – the site already has connections with the highway and is in close

proximity to the public transport and the existing surgeries.

Whilst the remaining sites were all potentially viable, the Project Team unanimously agreed that

the preferred site was more deliverable and had a smaller impact on the patients and residents of

Kempston that the other shortlisted sites.




Evaluation Criteria

The Project Team jointly developed the following criteria to be used in identifying the most

appropriate site. Evaluation criteria were grouped in to four categories; Access, Impact,

Functionality and Deliverability. A weighting of between 1-5 was applied to each evaluation criteria

by the Project Team prior to undertaking the evaluation of the sites.

Item Criteria Weighting

Access

1.1 Is the site next to multiple bus routes 5

1.2 Is the site next to a bus routes 5

1.3 Is the site in a suitable area 5

1.4 Can a junction be formed with the main highway or is there an existing

junction

5

Impact

2.1 Does the site avoid estate roads which may become congested with

additional traffic

5

2.2 Is the site centrally located to existing GP surgeries 2

2.3 Can surrounding parking be utilised 5

2.4 Will there be an ecological impact to the development 3

2.5 Does the site have restrictions on development (protected open space) 3

Functionality

3.1 Is the location suitable for 24/7 working 5

3.2 Is the site suitable for 24 hour working 4

3.3 Is there sufficient onsite parking 5

3.4 What is the flood risk rating 2

3.5 Are there any complimentary services in the vicinity 3

Deliverability

4.1 Can the site accommodate what is required? 5

4.2 Is there room for future expansion 1

4.3 Is the site in public body ownership 3




Item Criteria Weighting

4.4 Is the site vacant 2

4.5 Does the site align with the project’s timescales 4

4.6 Is there certainty of acquisition 2

4.7 Are there any identifiable planning issues 2

4.8 Are there any development controls in place 2

Table 8 – Site evaluation criteria

3.3.1 Results

The site evaluation process was conducted in one session with the Project Team all in attendance.

The following table summarises the results of the evaluation process. A breakdown of the scoring is

included in Appendix 6.

Ranking Score Site

1 74% Site 5 Kempston Police Station

2 47% Site 7 Robert Bruce School

3 44% Site 3 Land adj Kempston Pool

4 42% Site 2 Beatrice Street

5 41% Site 14 Land next to Challenger Academy

6 39% Site 1 Moorings

7 0% Site 12 Kempston Ambulance Station

8 0% Site 10 80 Bunyan Road

9 0% Site 4 Addison Howard Park

10 0% Site 6 Saxon Centre

11 0% Site 8&9 Land adj BT Offices and Offices

12 0% Site 11 Land next to pumping station

13 0% Site 13 Land next to Baliol Primary School

14 0% Site 15 Bedfordshire Police HQ

Table 9 – Site scores




3.3.2 Engagement feedback on location

As part of the development of this proposal a number of external stakeholders have received

updates on the project. This has included the Mayor or Bedfordshire and the Local Councillors who

represent Kempston and Wootton together with partners from each of the GP surgeries.

All parties were most recently updated between December 2019 – February 2020 and broadly

supported the proposed location. A copy of the presentation presented during December has been

included in Appendix 7.

All parties agreed that the central location in Kempston and the opportunity to reuse a site already

within public ownership and which the Police had confirmed they were already implementing an

exit strategy supported the delivery of the project.

3.3.3 Social vitality and mobility

In comparison to the wider Bedfordshire area, Kempston has a lower level of economic vitality that

the surrounding areas. However, deprivation within Kempston is not a major factor in the provision

of primary care within the four Wards. Although Kempston North is the most deprived amongst the

Kempston Wards, it is limited to small pockets affecting some of the population.

This is confirmed through analysis of those indicators, such as car ownership which shows that

Kempston is generally in line or above the national average for car ownership.

3.3.4 Access

3.3.4.1 Walking

One of the foundations of Primary Care is its provision within the community. As a result, it should

be as accessible as possible. Whilst not all patients will be able to walk to the surgery, irrespective

of distance, maximising opportunities for walking is highly beneficial in measuring how accessible a

location is.

The three existing surgeries account for 22,743 patients. Of these, NHS Shape data confirms that

93% of patients are within a 15min walk of the surgery2. In Figure 6 the yellow shaded area

illustrated a 15min walking time to the nearest surgery in Kempston. The green perimeter line is

used to estimate the number of resident’s base on Middle Super Output Areas.

2 Assumes that patients register with their closest surgery




Figure 6 – 15min walk time to existing GP surgeries in Kempston

As the three GP surgeries will be brought together on a single site, their spread through the town

will be unavoidably reduced. Following the move to the Kempston Police Station site it is expected

that 86% of patients will still be within a 15min walk of the MCCC (Figure 7). Whilst it is less than

the current provision it is substantially above the BLMK STP average of 76% of patients and the

NHS’s target of 69% of 15mins by foot or public transport.




Figure 7 - 15min walk time to proposed MCCC in Kempston

The BLMK STP and NHS statistic combines walking and public transport in its 15min journey times.

In the next section estimates of patient accessibility by public transport and on foot will be

analysed

3.3.4.2 Public transport

The provision of public transport for key services is essential in ensuring that they are universally

accessible and environmentally sustainable.

The following plan illustrates areas of Kempston that are within 15mins by public transport of one

of the three GP surgeries. As can be seen (Figure 8, this covers the majority of Kempston, Gibraltar

and Wootton to the south and central Bedford.




Figure 8 – Areas within 15mins by public transport of a GP surgery

Relocation of the three GP surgeries to the proposed site, as evidenced in Figure 9, illustrates no

impact on the residents of Kempston in their ability to access the proposed location by public

transport. Impact to any resident further-a-field is minimal as residents of Wootton, Stewartby and

Bedford town will continue to enjoy the same travel times as they currently experience when

accessing their surgery by public transport.

This outcome is expected as the proposed site sits within the cluster of the existing surgeries and is

located on the same bus routes. Bedford Road, which passes through the centre of Kempston and

is the main atrial transport route for the town.

The proposed location is within 200m of its nearest bus stop from which seven services depart

through the day. The majority of these routes come from the surrounding areas, through

Kempston and terminate in Bedford town centre. There are a few local services which travel around

Kempston before returning to Bedford, these also pass the proposed site.




Figure 9 - Areas within 15mins by public transport of proposed site

3.3.4.3 Private transport

Providing an integral part of the transport network, private transport is widely used throughout the

Borough with most wards in Kempston outperforming the national average of 26% of households

having no access to a car.

Kempston North 25%

Kempston Central and East 23%

Kempston South 16%

Kempston West 28% of households with no access to a car.

Despite the dependency upon private transport, limiting its requirement is desirable as it reduces

congestion, air pollution, noise and the chance of road traffic accidents. For this reason, key

services, such as Primary Care can help to reduce the use of private transport by locating centrally,

shortening the travel distance for the majority of people and encouraging access by walking or

public transport.

Where private transport is needed, BBC planning requirements stipulate a provision of 5 parking

spaces per consultation room or on merit in consideration of the travel plan3. A travel plan will

need to be included as part of the planning application, in which it will calculate the mode of

3 Non-Residential Parking Standards, Parking standards for sustainable communities.




transport people will likely use in accessing the MCCC. Given the central location of the MCCC in

Kempston, it is unlikely that 5 spaces per medical room will be required or desired. Over provision

of parking can discourage people from choosing other means of transport and result in large empty

carparks in the town centre, which is not only wasteful, but also unsightly and detracts from the

cohesion of the urban environment.

As there is already significant parking provisions in Kempston town centre (Saxon Centre), an

abundance of bus routes and 76% of patients within 15min walk, it has been anticipated that the

total number of parking spaces can be reduced to 3 bays per clinical room and a circa 100 space

carpark would be sufficient for the needs of the MCCC. Whilst this will need to be tested as part of

the Transport Assessment, it has been used for the purposes of developing cost estimates.

There is no notable impact on patient travel times who access the existing surgeries by car. The

existing surgeries and the proposed location have the same catchment within the 10min drive time

of 116,334 residents.

Figure 10 – Area within 15 min drive of proposed site

3.3.4.4 Summary of Mapping

Location plays an important factor in ensuring that patients can access the primary care services

they require. Location and site accessibility played an import part in the assessment criteria for the

site.

When transitioning from three site to a single central location, it is unavoidable that there will be

changes to journey times. However, by including criteria such as bus routes and distances from the




existing surgeries the Project Team have remained mindful of this factor and identified a location

that seeks to minimise travel times.

The preferred site of Kempston Police Station is located centrally between the existing GP surgeries

and, like the existing surgeries, is located on the main road through Kempston. As is expected, the

impact to the majority of patients has been minimised. Those most impacted will be patients on the

outskirts of Kempston who walk to the surgery. However, even walking time increases will be

minimal with increased journey times around 5-10mins. Those travelling by car or public transport

will have a negligibly longer journey time increase.

Options Appraisal

3.4.1 Assumptions

3.4.1.1 Income

BCCG has stated that the expected rental level for GMS space in Bedfordshire is £225/sqm,

however few comparable exist for newly built primary care facilities which could command a higher

rent. This would be applied to the lettable area, and is assumed to include all clinical space and

areas of the building that directly support this space. It excludes the areas associated with Planning

and Engineering allowance, but does include circulation space as this is essential to accessing the

clinical space.

The presence of PCN services and the substantial amount of space they require will require further

exploration in the OBC. Whereas in health centres built over the last decade have had a small

amount of space set aside for out of hospital services, the Kempston MCCC responds to the

challenge of providing an increased range of out of hospital services and the building has to

increase by around 40% to accommodate these services. It will therefore be unviable for the

practices to accommodate these services without recharging for the space if they are unable to

claim it as part of their GMS contract. The current specification of contracts issued under the PCN

will need to be reviewed and aligned to either include a rental amount, specified location or back to

back agreement with the commissioning body and the management of the MCCC to ensure non-

GMS services do not need to be subsidised by the GMS contract rent reimbursement payments.

For the scheme to be finically viable at present, a rental income of £353/sqm will need to be

obtained across the building. Work associated with the OBC will clarify and potentially reduce the

amount of rent needed to make the scheme viable, through the reduction of risk, optimism bias

and effective architectural design solutions to reduce circulation and engineering space.

In addition, a small pharmacy is planned to replicate the existing provision at Kings Street surgery.

This will also be charged the market rent of £353/sqm.

Annual income from the car parking has been include at £235/bay.

Additional rent reimbursement and associated costs payable to the GP Practice under Primary Care

Premises Costs Directions will need agreement and approval by NHS England at OBC stage.

3.4.1.2 Cost of site assembly

Purchase of the site has been assumed at £1.1m/acre as advised by BBC valuation department

who have recently undertaken the disposal of a similar site in Kempston. Although the police

station site is expected to occupy a 1.2 acres site the police station is 1.3 acres and it is expected

that the whole site would need to be purchased. By comparison the Robert Bruce sites is

significantly larger and it is assumed that a 1.2 acre site can be carved from the larger title. As a

result, the purchase the police station site is expected to cost more because it is slightly bigger.




The existing police station building is assumed to impair the value of the site by the cost of

clearance as no party, including Bedfordshire Police, would be able to use the buildings in its

current form. It is estimated to cost £583,560 (exc. VAT) to clear the site.

3.4.1.3 Allowance for abnormals

No specific allowance for abnormals has been made, beyond those included in demolition of the

site. A desk top survey of the history of the site has identified that prior to circa 1910 the site was

used for open space/farming. Around this time the main police station building at the front of the

site was built around this time. Subsequent buildings were added over the proceeding 100 years,

all associated with the police use of the site.

One of the buildings is used for servicing of blue light vehicles. Although this is a modern

construction it is possible that the ground may have become contaminated by hydrocarbons in the

course of its use. As this is underneath the existing building, it is expected that intrusive ground

contamination survey would be beneficial in ascertaining if contamination has occurred.

It is expected that the OBC and FBC will be responsible for commissioning intrusive condition

surveys of the building and ground as this is not normally undertake as part of a SOC. The

outcome of these surveys will need to be costed and included in the overall appraisal.

3.4.2 “Do nothing”/ “Business as” usual Option

Developing a viable business as usual option has proven challenging. All three existing sites are

landlocked with very limited space for expansion. The surgeries have a combined clinical space

deficit of 763sqm against best practice recommended to meet their existing requirements under

their GMS contracts.

St Johns surgery, already utilises temporary buildings to provide additional accommodation. These

have exceeded their life expectancy and it is no longer economical to maintain/repair.

At the King Street surgery, it has leased adjacent land to enable a wheel chair user access and

welfare facilities to be built in addition to a number of clinical rooms. Over the course of the project

the landlord terminated the agreement. Cater Street is similarly constrained from developing.

In consultation with the CCG each surgery is able to close its List for a period of time to help

distribute new patients across the PCN, however this does not offer a long-term solution,

particularly in light of the ongoing housing development in the area.

To address the needs of patients and meet the aspirations of the collaborative working under PCNs

a threefold increase in the amount of clinical space is need.

As a result, whilst a ‘do nothing’ option whilst able to maintain the aging estate, it will

be insufficient to address the existing shortfall in clinical space, a problem what will

worsen year on year as new housing already under construction, becomes occupied.

3.4.3 Criteria for identifying options

The SOC has identified that substantial increase in the clinical floor space is needed in Kempston to

enable it to serve the local population and achieve the goals of PCNs with out of hospital services.

3.4.3.1 Expansion of existing sites

All sites are landlocked and whilst one has been able to lease adjacent land, the landlord has

already terminated the agreement in order to secure a higher rent. As the King Street surgery is




dependent on the leased land for is accessible welfare facilities, entrance and a significant number

of clinical rooms, there is a significant risk the landlord, could if they chose to, exact increasingly

higher rental amounts from the surgery because of this dependence.

Even with additional space leased on the adjoining plot, it there is currently insufficient space in the

surgery to meet the needs of patients.

3.4.3.2 Preferred option

The preferred option is to develop a new facility in Kempston that is able to

accommodate all practices and provide sufficient clinical space for the out of hospital

services to be provided in the same building allowing healthcare professionals greater

oversight into a patient’s wellbeing.

3.4.3.3 Variant option

Whilst it is preferable to develop a new building capable of accommodating the three practices and

a range of out of hospital services, relocating two of the surgeries is possible, however not deemed

at this time to be practical. This is due to the size and scales of the three surgeries, two of which

are substantially smaller than the third.

To obtain the increases in clinical that is needed by relocating only two surgeries, the most cost-

effective solution would be to relocate the two smallest surgeries into a larger building, thus

creating two medium sized buildings.

Whilst King Street, operates at scale, with a number of partners, GPs, trainees and range of

supporting clinical and non-clinical staff, the Cater Street and St Johns surgeries have only 1 and 2

partners respectively. As a result, their structural capacity to significantly expand does not yet

exist. Both surgeries would need to significantly increase their capacity through the recruitment of

new GPs and support staff. Such rapid growth would inevitably require any business to take on a

substantial amount of debt with which to forward finance the expansion putting stain and risk on

the continued operation of the practices.

For the reason of ensuring stable and gradual growth of the three practices in Kempston it is

strongly recommended that the largest of the surgeries be involved the new facility.

A further variant would to be relocate all three practices into a new smaller building, whilst keeping

the King Street surgery operational. This option is also not desirable. It would require King Street

to split its workforce over two sites, resulting in new management challenges and a disjointed

primary care provision. Alternately it could create a branch surgery in the MCCC, however the

practice has no experience of this type of operation and leading it as a result of an estates solution

brings with it substantial risk and potential for error in the long-term maximisation of investment.




Development Appraisals

A development appraisal has been completed for the Police Station site. A full breakdown is shown

in Appendix 8 and Appendix 9. Estimated income for both sites are the same, irrespective of the

site chosen.

Total costs follow the same principal, in that each site would cost the same to develop, however

the police station is slightly bigger and has an existing building. The cost of demolishing the

existing building does not impact appraisal as it is netted off by a reduced purchase price.

However, as the site is slightly bigger (but considered too small to carve off from the main title)

the police station is more expensive to develop.

Site Police Station Robert Bruce

Estimated Annual Income £666,555 £666,555

Estimated Total Costs £14,546,800 £14,055,949

NPV at 3% £0 £490,851

Table 10 – Summary of Development Appraisals

Risks

The development appraisal has a 10% Risk Allowance and 10% Optimism Bias included.

Collectively this increases the build costs by circa £2.2m.

As the project progresses through OBC and elements of the project are de-risked or confirmed,

these sums can be released. The released sums can be used to further enhance the proposal,

improve the rate of return or reduce the amount of funding needed.

NPV, Optimism bias and sensitivity analysis

The Robert Bruce site returns a higher NPV primarily due to the absence of remediation needed on

the school’s playing fields where this site would be located.

Both NPV’s assume a 3% yield and rental income of £353.15/sqm (building total rental of

£666,555pa). Other operational costs have assumed to be on nil effect on the viability of the

scheme and should be developed further in the OBC.

The NPV only illustrates which site has a better financial return and done not consider the overall

viability of delivering that site or the fulfilment of the objectives of the MCCC.

Cost Benefit Ratio

The Project Team agreed to weight scoring or the quality and cost elements of each site on a 40:60

(quality:cost) basis.

The Police Station and Robert Bruce sites scored 74% and 47% respectively. Overall the Police

Station is expected to cost an additional £490,851 over the Robert Bruce Site to deliver. As a

result, the Robert Bruce site, as the lowest scoring site, received 100% for cost. By comparison the

Police Station site received 97% as it is 3% more expensive to deliver.




Site

Site Cost Site Cost

Total

Unweighted 40% 60%

Police Station 0.74 0.97 30% 58% 88%

School 0.47 1.00 19% 60% 79%

Table 11 – Cost to benefit ratio

Following the application of a cost benefit ratio the Police Station and Robert Bruce sites score 88%

and 79% respectively. The recommended site to be taken forward to OBC is therefore the Police

Station site.

Summary

Cost and quality analysis of each the two preferred sites has identified that the Police

Station site in Kempston is the most suitable location for the proposed MCCC. Although

slightly more expensive to deliver, its propensity to be delivered, central location and

existing use led the Project Team to conclude it has substantial non-fiscal benefits over

the site of the former Robert Bruce Middle school.




4 Commercial Case

The commercial case focuses on identifying the procurement route best suited to ensuring delivery

of the “preferred option”. It includes the planning and management of the procurement of the

“preferred option” and is in accordance with European Union (EU) and Word Trade Organisation

(WTO) rules and the current regulations for the public sector procurements.

It also specifies the service requirements for the proposed investment in the MCCC, together with

the anticipated charging regime and the allocation of risk in the each of the design, build, funding

and operational phases.

Finally, it includes the contractual arrangements and specifies the accountancy treatment to be

used for the proposed service.

Procurement Strategy

4.1.1 Procurement options

This section explains potential procurement options available for use within the project, and

includes:

Procure 21+ / Procure 22

Traditional Tender

Design and Build

Private Finance Initiative (PFI)

Express LIFT

LIFT Partner: Management of Design

and Construction Elements Only

3rd Part Development (3PD)

Social Enterprise

Joint Venture (JV)

The key issues relating to each of the procurement options are summarised below:

4.1.1.1 Procure 21+/22

ProCure 22 (P22) is a framework of contractors originally set up by NHS Estates (subsequently

managed by DH Estates and Facilities) for schemes being procured with public capital. The

contractors on the framework have been selected through the OJEU procedure and therefore are

not required to go through this procedure again, thus saving time.

A shortlist of contractors can very quickly be selected, interviewed and a preferred contractor

selected. The contractor is selected on the basis of their methodology, proposed programme, team

and interview. The PSCP would then work with the Project Team to prepare the design and agree a

guaranteed maximum price (GMP) before starting on site. This procurement route requires the

scheme to be funded through Treasury capital (or through internally generated funds in the case of

Foundation Trusts).

Advantages Disadvantages

Single point contact and responsibility

Inherent buildability

Early Guaranteed Maximum Price (GMP)

Reduced total project time

Partnering approach to problem solving

Early stakeholder engagement

Early design/cost certainty

Sometimes difficult for clients to prepare

adequate employer’s requirements at an

early stage

Client driven changes can be expensive

post GMP





Existing relationships and project history

Known up-front charges for project

front-end development

Sub-contractor work packages tendered

competitively

Open-book accounting

Satisfactory public accountability

Private Sector Competitiveness Project

(PSCP) Incentivised

Compliance with the “Common Minimum

Standards” OGC, 2006

Not flexible in the event a GMP is not

agreed

Is time consuming in the event a GMP is

not readily agreed

Potential for design quality to suffer due to

the PSCP contractor being possibly cost-

driven

Possibility to over-price in order to

increase contractor share of savings

4.1.1.2 Traditional Tender

As with ProCure 22, these procurement routes are for schemes being funded by public capital. Both

methods require NHS organisations to procure a contractor through the OJEU procedure.

Under this procurement arrangement, the responsibility for construction is in a single contract,

separate from the design, utilising either Bills of Quantities or Specifications and Drawings. Bills of

Quantities should only be prepared once design has been fully completed. Such a document

provides measured quantities that allow competing contractors to price all material, plant and

labour used on the project to arrive at a “lump sum” tender for the project.


Open, competitive tendering

Procedures well known

Client has potential cost certainty before

start of construction

Sub-contractors are under the main

contractors control

Slow to start on site (no parallel working)

Contractor not involved in design or

planning (no buildability, unless a two

stage process is used)

Heavily reliant on the quality and

completeness of tender documents

Adversarial

Can be subject to costly “claims” if design

information is issued late or incomplete

Variations can cause delay and claims

Not supported by OGC “Common

Minimum Standards” 2006

Does not deliver the project front-end

engagement process to deliver VFM

Nationally, problems historically with

programme, cost, quality and final

accounts

Required to procure a contractor through

the OJEU procedure.

Due to requirement to procure a

contractor through OJEU, procurement

could take 6-9 months




4.1.1.3 Design & Build

As with ProCure 22, these procurement routes are for schemes being funded by public capital. Both

methods require NHS/Public organisations to procure a contractor through the OJEU procedure.

The ‘Design & Build’ method involves the Project Team or lead partner working up the design to a

certain stage and procuring a contractor on the basis of its proposals to complete the design and

construct the building. The Project Team or lead partner could then either novate their own design

team to the contractor or allow the contractor to bring their own design team.


Competitive tendering ensures VFM

Satisfactory public accountability

Procedures well known

Possible single point contact and

responsibility

Inherent buildability

Early firm price possible

Reduced total project time

Significant risk transfer

Sub-contractors and design team under

the main contractor's control

Client needs to commit before design is

complete

No design overview unless client retains

design team or appoints due diligence

consultant – extra expense.

Client driven changes can be expensive

Potential for design quality to suffer due

to the contractor being primarily cost-

driven

Potentially adversarial

4.1.1.4 Private Finance Initiative (PFI)

PFI is a form of Public Private Partnerships (PPP) that has successfully delivered public

infrastructure buildings for over 10 years. The contract is a concession contract for 25-30 years for

the partner to design, build, finance and maintain the facility for the concession period.

A key aspect of PFI is that the partnership or lead organisation would only pay for the building or

elements of the building if they are ‘available’ for use. Should the building fall below minimum

standards or areas of the building be ‘unavailable’ for use, the partnership or lead partner

organisation would be entitled to deduct money from the Unitary Payment.

Variations to requirements during the construction phase can be costly and therefore it is

imperative that the building be designed to be flexible and easily adaptable. Procurement times can

be lengthy if not managed correctly or if poor quality or insufficient information is provided at the

tender stage. HM Treasury guidance indicates that PFI is unlikely to be a cost effective

procurement route for capital schemes whose capital value is less than £25m.

4.1.1.5 Local Investment Finance Trust (LIFT) / Express LIFT

LIFT, operated by the Community Health Partnership (CHP), was developed an alternative form of

PPP with a number of advantages over PFI. LIFT was introduced to give flexibility to Primary Care

Trust’s working with a partner to build primary care resource centres within the local community of

a fixed geographical area. The LIFT partner constructed premises on behalf of the PCT and offered

them to the NHS partner on a Lease plus Agreement (LPA). The LPA obligates the LIFT partner to

maintain the building and, in some instances, provide soft services on behalf of the NHS

organisation for the duration of the LPA (25-30 years). At the end of the concession the NHS

organisation could either renew the lease or walk away with the LIFT Partner taking the benefit of

the asset to find an alternative use for the land and/or building.




Express LIFT represents a short form of the full LIFT contract for smaller projects where a full LIFT

approach is not appropriate. It is designed to be quicker to implement.

LIFT projects are, however, becoming increasingly unpopular procurement solution due for similar

reasons as PFI and is not currently advocated by the Strategic Estates Advisor supporting this SOC.

4.1.1.6 Third Party Development (3PD)

A ‘Third Party Developer’ is a developer who funds and builds a new facility in return for a lease

payment from the NHS/Public Sector Partnership and, potentially, other tenants. Under the 3PD

approach, the development company forward funds the project and receives a share of

development profits. The Project Team or lead partner organisation would normally enter into a 15

year FRI or TIR lease with the developer with agreed rental levels and rent reviews every 3 years,

these can be based upon open market rent, set increases or a cap/collar.

Bedfordshire CCG is currently developing a scheme elsewhere in the region with a 3PD. The skills

and experience developed on that project could be brought forward to support the delivery of

Kempston MCCC.

4.1.1.7 Joint Venture (JV)

JVs offer public sector organisations (PSOs) the opportunity to share the risk albeit with a lower

share of the return. Partners in JVs typically bring capacity, expertise and investment, enabling a

more commercial approach, but they need to be chosen with care. There is an emerging breed of

JVs within the public sector in which councils or health organisations partner with commercial

companies that are themselves wholly-owned by the council or health organisation. Their

commerciality combined with public sector ethos makes them a viable option compared to the

more traditional public-private partnerships (PPP). Research into JV’s provided the following

learning:

Be clear on your objectives for setting up a JV such as income growth, cost savings

and value to the community - if all you want to do is deliver savings, outsourcing may be

better.

Take time in the procurement process - you need to be confident that the procurement

process is capable of delivering the right JV partner who shares your values but also has the

capacity to deliver.

Create a culture of trust and strong working relationships - there should be a ‘one

team’ ethos between the council/health organisation and the JV, and an understanding of

the importance of communication across all stakeholders.

Share profits and risk - it should not be possible for one party to benefit at the loss of the

other partner.

Anticipate the changing environment in which the JV will operate throughout its

lifetime, both operationally and politically - put in place mechanisms to address future

tensions, not just formal dispute processes but also regular meetings and guiding principles

for how to expect to manage the relationship which will allow it to evolve and eventually

exit.

Allow the JV to operate independently - the JV must be able to operate outside of the

council/health organisation focusing on income growth alongside improved service delivery

and cost-reduction. The temptation to make the JV another corporate directorate that acts

in the same way as others needs to be resisted.




This route may be difficult to follow as the land is normally the PSOs contribution to the scheme

and in Kempston both land and building need to be procured.

4.1.1.8 Procurement strategy

Key considerations when selecting which procurement route to choose are:

Time

Certainty of time

Certainty of cost

Price competition

Flexibility

Complexity

Quality

Responsibility

Risk

Value for Money

These considerations can be developed by the OBC into criteria for selection of the appropriate

procurement route for the MCCC.

4.1.2 Delivery

4.1.2.1 Site Acquisition

Either site must be acquired, or certainty of acquisition obtained for the project to progress. The

Police Station site has the easiest path to acquisition as it is already held by a public body and

there are no restrictions on the title or use of the land. Discussions with the Bedfordshire Police

have confirmed their intention to dispose of the site, with some of the persistent uses of the site

being transferred to sites owned by other public bodies, highlighting the willingness of the Police to

work in partnership with other public bodies.

Acquisition of the former Robert Bruce site will be significantly more challenging as the land is

intended for educational use. A proposal to construct a new school on the site for children with

complex needs has been submitted, but awaits Ministerial approval to progress. A masterplan for

the site has been developed and the site for the MCCC would need to be carved from the parcel

intended or housing. Adding a further party into an already complex development proposal

introduce a significant amount of acquisition risk that is not present on the Police Station site.

Discussions with the Police have confirmed they anticipate decommissioning the site by March

2022. The proposed programme within the document sets out how this would align with the

delivery of the MCCC.

No discussions have been held with the Police around likely values. However, it is anticipated that

they will be required to demonstrate best value in disposing of the site. Comparable valuation in

formation has identified that that could be as much as £1.1m per acre.

The less favourable Robert Bruce site is in ownership of the Challenger Multi Academy Trust. The

Trust are bring forward plans to redevelop the site. It is anticipated that the site would need to be

purchased from the Trust in order to allow the MCCC to be built. The Trust is also obliged to seek

best value from any disposal. As a result, both sites are expected to have headline values at the

same level.

A key difference between the two sites is the need to demolish the police station, where as the

school site offers a remediated site on which to build. However, the demolition cost is expected to

come off the sale value. The police station is a purpose-built building, for which no other owner is

likely to have a use for, including the police who site its obsolescence as its main reason for




disposal. It is therefore reasonable to assume that the presence of the building devalues the site as

any new owner would need to first clear the site before they could make use of it.

Consequently, site assembly and preparation are is anticipated to be broadly the same for each of

the two sites.

As a result, the key factor in determining which site to develop focuses on ability to deliver each

site.

4.1.2.2 Delivery Partners

Below we have summarised the possible delivery partners who could deliver the new MCCC:

Local Authority – through the course of the SOC development BBC has indicated that it

may consider being a development partner for the scheme, provided it offered a financial

return that in line with the Council’s investment objectives of non-core investments. BBC

has the existing skills and in-house expertise to deliver the scheme, however at present the

scheme’s rate of return are potentially too low. The Local Authority has indicated that they

would require a return on investment (ROI) of circa 7.5% to ensure the cost of borrowing is

covered. This should be reviewed at OBC once greater financial certainty is achieved and an

updated position on the cost of borrowing is known.

Third Party Developer (3PD) – there are a range of third-party developers who operate

in the health sector, either as dedicated health sector providers or through an arm of their

wider business. Companies such as Assura, Montpellier Estate and Primary Healthcare

Properties PLC are dedicated investment company who specialise in primary care sector

capital projects. Assura and organisation like it in the market place have a detailed

understanding of delivering capital projects and are therefore able to manage their exposure

to risk more efficiently that other developers or the Local Authority. As a result, these

companies are willing to undertake riskier and more marginal projects that those unfamiliar

with the market are unwilling to invest in. As a corporate entity they often have access to

capital funding.

Community Health Partnership (CHP) – works with commissioners and local parties

within England to develop investment opportunities within the health sector. As with the

other parties they are able to deliver projects and retain the expertise needed to manage.

NHS Property Services – a dedicated organisation supporting the NHS on all property

matters. They are able to develop new properties and retain the expertise to manage them.

Although similar to those mentioned previously, it is more reliant on funding initiatives due

to its ties to the Public Sector and therefore is not always able to generate capital as easily

as a 3PD.

Whilst each option offers a potentially deliverable route, the OBC will need to consider each option

in turn as part of its overall consideration of procurement to identify which route will optimise the

delivery of the MCCC.

4.1.2.3 Rent

The passing rent needs to be £353.15/sqm for the new build MCCC to be financially viable given

the current level of cost and a 3% return on investment. This has been calculated on a discounted

cash flow basis and included in Appendix 8 and Appendix 9. It is estimated that if the optimism

bias and risk can be released form the project this rental requirement can be reduced to around

£300/sqm and still return a 3% Return on Investment (ROI) without the need for gap funding.




This is more than the current rent passing in the area, however substantially below other parts of

the country where land values are substantially lower. BCCG will need to work with the District

Valuer’s Office to review prime rents in Bedford and potentially bring them in line with the rent

being attracted to other similar new build properties elsewhere in the country by highlighting the

MCCC’s improved quality, facilities and overall value for money.

4.1.2.4 Team

BCCG is currently developing new primary care facilities with a national contractor. Due to the tight

margins and the benefits of using an experienced contractor in supporting the design and delivery,

it could be beneficial to bring a contractor on to the project at OBC stage. Whilst it is not essential,

a contractor partner is able to reduce build risk and support the architect to improve the

buildability and efficiency of the construction, helping to reduce the cost of the overall project.

The OBC and FBC will also require the following services:

Architect

Structural, Civil and Mechanical &

Electrical engineer

OBC and FBC author

Healthcare planner

Cost manager

Project manager

Geo and Topographical surveys.

SOC to FBC Process

The SOC has set out the strategic case and need for change whilst developing, at a high level a

deliverable concept, by understanding the size, function and location requirements of a new MCCC

in Kempston.

The OBC will explore in further detail those requirements identified in the SOC by developing a

design and using this detailed space assessment to refine and de-risk some of the costs of the

project. The following diagram illustrates the key activities for each business case stage:

SOC

•The concept state:

•Ascertains 'stratigic fit'

•Makes the case for change

•Determines short list of potentail affordable options

•Conveys management capacity and cabuilty to deliver

OBC

•The detailedappraisal of options:

•Determined the best VFM solution

•Prepares for procurment

•confirms funding and affordabuilty

•the detailed management plan for deliver

FBC

•A final, tehcnical document:

•The outcome of the procurment process

•Final check on affordabuilty and VFM

•Contract details

•Comprehensive delivery plan and benifits realisation




At each of the three stages (SOC, OBC and FBC) the business case needs to consider each of the

five cases. The emphasis is different for each case at the respective stages. The priorities for each

section are illustrated in the table below, these reflect the core purpose of the document at the

various stages of the business case lifecycle:

Five

Cases Strategic Economic Commercial Financial Management

SOC Key step 1:

Ascertain the

strategic fit

Key step 2:

Make the case

for change

Key step 3:

Develop a long

list of options

and agree a

shortlist

Outline the

procurement

options

Estimate costs

and revenue

for shortlisted

options

Proposed

management

arrangements

OBC Review any

significant

changes and

implications

Key step 4:

Determine

value for

money

Key step 5:

Prepare for the

potential deal

Key step 6:

Confirm

funding and

affordability

Key Step 7:

Plan for

successful

delivery

FBC Review and

minor changes

and

implications

Confirm value

for money

Key step 8:

Procure the

solution

Key step 9:

Contracting for

the deal

Confirm

financial

implications

and financing

Key Step 10:

Ensure

successful

delivery

Figure 11 – Key features of the Business Case Model

Attractiveness to the market

Assuming site acquisition can be achieved, the similar costs of each scheme mean that either is

likely to be attractive to the market, provided rental figures can be agreed with the Valuation Office

Agency (VOA). Both schemes return around 3% yield. Whilst this is low, GP surgeries make for

very safe forms of capital investment as they are ultimately backed by the NHS through the

through rent. Companies such as Assura and Wilmot Dixon who specialise or have arms of the

business that operate in this area are likely to be interested in this project.

High level discussions with the market have identified that a number are active in the wider area

and looking for investment opportunities.

Discussions with the surgeries has identified that they are unlikely to be interested in forming a

development company to deliver the building. Similarly, the Local Authority has indicated it may

consider investing in the site however, as provision of health services and buildings fall out with the

remit of Local Authorities, they would likely seek a higher return than specialist provider to need to

limit exposure to risk when partaking in non-core investments. As a result, a 3PD would potentially

offer the same level of service but with a lower financial cost to the project.




Timetable for procurement

The following table sets out a high level procurement route for production of the OBC and FBC. A

number of months have been allowed to secure approvals as there will be an increasing number of

organisations involved in the OBC and FBC.

Stage Start End

SOC Approval March 2020 June 2020

OBC Tender July 2020 October 2020

Write OBC October 2020 April 2021

OBC Approvals April 2021 October 2021

FBC Tender October 2021 December 2021

Write FBC January 2022 April 2022

FBC Approval April 2022 October 2022

Table 12 – Indicative timetable

The schedule does not include for any pauses to the programme that might take place as a result

of changes to government policy or periods when funding initiatives may not be active.




5 Financial Case

The purpose of this section is to set out the financial implications and considerations of the MCCC.

The total project costs is expected to reduce over the lifetime of SOC to FBC as items held as risk

are committed or released and design work is commissioned during the OBC stage.

Capital Costs

5.1.1 Site Acquisition

The preferred site of Kempston Police Station is currently under the ownership of Bedfordshire

Police who hold its freehold. As a public body, Bedfordshire Police will be obligated to obtain best

value for its disposal.

In estimating the value of the sites, recent comparable information provides the most appropriate

method estimating the value of the site. Bedford Borough Council has recently sold land at Baliol

Road at £1.1m per acre. The site is with vacant possession and with no significant abnormal costs

to consider.

As the Police Station is 1.3 acres it suggests a vacant possession value of £1.1m.

It is assumed that the police would not undertake the demolition of the building and that the

structures are of no use to any other future purchaser of the site. They are therefore treated as an

impairment to the site and the cost of their demolition would be deducted from the open market

value of a comparable site that had no structures upon it.

Clearance of the site is estimated at: £583,560

The estimated value of the site is therefore: £846,440

Allowing for Stamp Duty Land Tax and likely surveyor and legal fees the estimated cost to acquire

the freehold title of the site is £895,191.

As no surveys of the building or ground to have been conducted these costs are estimates based

on the available limited information and should be further tested in the OBC and FBC.

5.1.2 Building

The cost to construct the building, once the site has been assembled and cleared remain that same

for each option. The building is estimated to cost around £9m to deliver at a cost of £3,953/sqm.

However, there are other associated in addition to the previously mentioned land assembly and

preparation such as externals works, these would add a further £1m to the cost of the overall

building.

Details of cost for comparable schemes have been included in Appendix 10 for reference. These

costs have been standardised and adjusted for time and geography to ensure they are directly

comparable.

5.1.3 Other costs

At this early stage of the project there are also further costs needed to get the project to site.

These include production of the OBC and subsequent FBC, together with ground surveys.

As these have not yet been undertaken the development appraisal retains around £2m of

risk/contingency in the form of Risk Allowance and Optimism Bias. A decision of whether to convert




these contingencies into costed items or release them can be made from the OBC stage onwards

once the initial design is completed and site survey information beings to infirm the design.

5.1.4 Total Project Cost

The estimated total project costs of the preferred Kempston MCCC is £14,546,800 and

includes all costs identified previously (Land, Build and Other costs) a full break down in included in

Appendix 8. Some of these are enabling costs and may be secured from external funding sources,

reducing the overall cost of the project, such as One Public Estate, under which funding this SOC

was procured.

In addition, prior to the completion of the OBC elements of design and investigation will be

commissioned. The effect of this expenditure through the OBC will be to reduce the total project

costs when next reported in the OBC submission.

Rent Reimbursement

The primary source of funding for the scheme will be through capitalisation of the Rent

Reimbursement as no grant funding is available and Section 106 is not considered likely.

The market rent for new build health centre is relatively untested as there has been limited

development in the area. A rental amount of £225/sqm would likely require around £5m of grant

funding to be viable. The project has been illustrated to be viable with a rental income of circa

£353/sqm however with the reduction of risk and optimism bias, the capital funding requirement of

the project could be reduced by up to £2.2 million and therefore could be sustained by a lower

rental income of around £300-315/sqm.

Other options include funding from schemes like Estate & Technology Transformation Fund (ETTF).

Although due to conclude in 2021, it is anticipated that a replacement fund will come on line to

take its place and a new round of bids will be sought from CCGs

Sustainability and Transformation Partnership (STP) or Integrated Care System (ICS) capital

funding could also be considered. Presently the Bedford Luton and Milton Keynes STP is currently

developing. Once establish it is likely that it will identify schemes form across the BLMK area for

capital funding.

Although not active at present, it is anticipated that the government will soon announce a new

tranche of funding aimed at improving access to GP services.

Other building Costs

5.3.1 Facilities management costs

Costs to manage the building have not been developed in detail and will evolve from works to the

design, selection of materials and specification of plant and machinery. The procurement route will

also have an impact on the running cost, and who has to pay them, with many healthcare building

developers retaining the obligation to maintain the building and charging the tenant for that

service. It is expected that the building will cost in the region of £50/sqm to operate. Whilst rapidly

evolving green technology can reduce install cost and energy demands, labour costs continue to

increase.

Modern Methods of Construction and off-site construction can help to reduce upfront costs,

although they invariably have shorter life expectancies and higher maintenance costs towards the

end of the life cycle.




VAT Treatment

Further advice on the treatment of VAT will be required at OBC/FBC stage. This advice will be

sought and presented at that time.

Revenue affordability

The rent currently paid to the existing surgeries in Kempston is around £120-150/sqm. This low

level reflects the age and quality of the buildings. Due to the increased quality and size of clinical

space proposed the gross rental payment will need to increase from around £125,000pa to

£666,555pa (£353/sqm).

Such a large increase will bring significant budgetary and affordability challenges to the CCG who

ultimately will be required to pay the rent. The CCG will need to review its budgetary commitments

over the coming years to be able to support this scheme.

Detailed expenditure of the individual surgeries will also increase significantly. Some of the

practices undertake their own repairs, snow clearance and landscape works. Directly undertaking

the work artificially lowers the existing operating costs as it often done at nil cost. Relocating to a

new managed building will generate new costs beyond increases for scale.

CCG Rent Reimbursements

BCCG has committed to reimbursing the rent, rates, water and clinical waste costs of the new

building. The rental amount will need to be approved by the District Valuer. Although no District

Valuer has been appointed for this scheme, other comparable schemes in the Bedfordshire area

have been valued at £225/sqm. Without grant funding the Kempston MCCC s estimate to need

between £300-350/sqm to be financially viable.

As the combined patient list is currently 22,743 patient with an expected additional 583 patients

expected to register in the coming years the total list size has been calculated at 23,326 patients.

The CCG will reimburse rent on the GP consultation and treatment space; administration and

circulation space within the NIA; stores and essential welfare facilities. Plant and circulation space

beyond the NIA would not be reimbursed. Guidance on these elements form the Premises Directive

does state that local variance is possible depending on the structure of the occupation agreement.

Sensitivity analysis

Due to the early stage of the project, a sensitivity analysis has been undertaken to stress test the

assumptions. The project’s infancy means that there is a considerable amount of ‘risk’ contained

within all costed assumptions should any unforeseen cost emerge. As the project matures, items

held as risk are converted to costed items or released. Releasing risk and contingency sums once it

has been demonstrated that the funds are no longer required reduces the project budget and

improves its financial viability.

5.7.1 Risk and Contingency sums

There are a number of areas where risk is currently included in assumptions in lieu of having

completed detailed designs and surveys of the site, and include:

Planning Allowance – 10% of the building size in accordance with HNB11.01 guidance

Risk Allowance – 10% of the project cost totalling £1,128,000

Optimism bias – 10% of the project cost totalling £1,241,000




As a detailed design is developed in the OBC the Planning Allowance can be converted to a fixed

dimension. Risk and Optimism can be reduced once the design and surveys are completed, but it is

likely that an amount for risk will be held until practical completion to account for any unforeseen

events during construction e.g. contingency funds.

5.7.2 Grant Funding

As no grant funding has yet been secured for the project, none has been shown in the cost

calculations used in this SOC. However, the increasing importance of primary care within the health

service and historic funding initiatives, suggest that the project may be able to apply and obtain

funding in the future. Available funding should be reviewed during the OBC stage.

Grant funding will offset some of the capital costs, improving the overall viability of the scheme.

5.7.3 Reduced Costs

Although inflation typically means costs increase over time, technological advances or process

changes can mean that inflation is offset by a cheaper way of delivering the same project. Modern

Methods of Construction (MMC) and modular builds are still emerging throughout the construction

industry. As they become more established the cost of these options is likely to reduce and may

reduce the overall build cost through reduced material requirements, utilisation of cheaper

materials, or shorter construction periods (from which savings on prelims can be obtained).

5.7.4 Yield

Yield is a return measure for an investment over a set period of time, expressed as a percentage,

and tend to be market led and whilst they can be forecast, the final amount will vary depending on

how the market views the proposal at the time. Yields of 3-3.5% are typical reflecting that a

property investment has more risk and a Government bond, but ultimately incomes are still

Government backed (through the CCG, NHS and ultimately central Government). However, a

developer can apply a lower yield if they feel the long term return of the project are particularly

good. Alternatively, in a competitive situation a developer can outbid a competitor with a lower

yield to secure their investment in the project.

5.7.5 Sensitivity analysis

In undertaking the sensitivity analysis, the following assumptions used in this proposal have been

kept constant:

Total project cost -£14,546,800

Rental Growth 2.5% pa upwards only adjusted every 5 years

Period 25 years.

By varying the project cost/grant funding and the yield the revenue needed to support the project

can be analysed.

This SOC has assumed a 3% yield with no grant funding (see rental figure highlighted in red). By

increasing the grant, the rental income needed to support the scheme is reduced. Similarly by

increasing the yield (return for the investor) the rent needed to make the project viable has to

increase.




Grant funding or reduced

cost

Yield

0.0% 2.5% 3.0% 3.5% 5.0% 7.5% 10.0%

£ - £237.26 £331.87 £353.24 £375.41 £446.64 £580.13 £729.85

£ 500,000 £229.10 £320.46 £341.09 £362.51 £431.29 £560.19 £704.77

£ 1,000,000 £220.95 £309.05 £328.95 £349.60 £415.94 £540.25 £679.68

£ 2,000,000 £204.64 £286.24 £304.67 £323.80 £385.23 £500.37 £629.51

All values are £/sqm

Table 13 – Sensitivity Analysis

From Table 13 it is possible to identify that if the OBC is able to release the £1m of the optimism

bias the rent needed to achieve a 3% yield could be reduced by £25/sqm. Similarly if a developer

will only commit to with a 3.5% yield the project will need an additional £25/sqm, unless it can be

offset by grant funding or cost savings.

Summary of Financial Case

Financial expenditure by the CCG will need to increase in order to meet the costs of

delivering and operating the proposed primary care estate, which is both substantially

bigger and of enhanced quality.

The building is expected to cost between £14-14.5m to build and budgetary allowance

will need to be sought by the CCG during the OBC period should the building come on line

within the proposed timescale of 2022/23.




6 Management Case

The Management Case demonstrates that the preferred way forward/option is deliverable and

explains how the project will be managed and governed, how the expected benefits will be realised,

how risks will be mitigated, how change will be managed and the anticipated timescales for

delivery.

Approvals and Support

6.1.1 Approval of this document

The formal approval of this document will need to be made by the BBC as the commissioning body

having accessed OPE funding. However, as the CCG is an integral stakeholder, and best placed to

take this SOC forward, will also need to be seek internal approval before taking it to NHSI/NHSE at

national level. Any proposed developments will need to become part of the STP’s key estate

priorities, which will need direct involvement from the CCG to achieve this.

Project Management

Where a project involves multiple stakeholders, as with the MCCC in Kempston, it is important to

identify a “lead organisation” to manage the planning and implementation processes. It is not

unusual for the “lead organisation” to change as the project progresses. BBC has led the

development of the SOC through its access to OPE funding. However, as the scheme develops the

CCG will be best placed to lead the development of the OBC and onto FBC of the OBC.

The development of the SOC for the Kempston MCCC has been led by BBC in conjunction with

BCCG. Whilst it is appropriate for this partnership approach to continue, it is expected that a single

lead organisation will be identified for development of the OBC. It is likely that BCCG would need to

be the sponsoring body for the OBC, although this could be a different role from that of “lead

organisation”. Whichever organisation takes the lead, the involvement of and alignment with the

wider BLMK ICS Out of Hospital Services Programme, will reinforce the integrated approach that

has been adopted to date.

To complete the OBC, a business case author and healthcare planner supported by a design team

will need to be appointed. Detailed involvement of the three GP practise will also be required to

ensure the design reflects the needs of the local community.

It is recognised that a more robust governance structure is needed to take the scheme forward

that will require formal commitment from all parties included.

The diagram overleaf outlines a proposed governance arrangement to get to the end of an OBC to

support both the development and delivery of the preferred option.




Figure 12 – Project Team structure for OBC

Project Board – Responsible for setting the key objectives, success factors and direction of

the project at OBC and FBC. They will also need to approve the final proposal and should

therefore have representation from the CCG.

Project Manager – Will be tasked with coordination of the various consultants on behalf of

the Project Board.

Finance and Funding workstream – Working with the Design Team, this workstream will

need to investigate those funding streams identified previously, identifying which route are

the most appropriate. They will also need to hold an ongoing dialogue with the VOA to

ensure they final assessment aligns with revenue assumptions.

Design Team – Commonly headed by the architect, OBC author or project manager, the

design team will be responsible for developing a deliverable building that takes into

considerations the requirements of the healthcare planner.

Business Case Author – Will be responsible for production of the OBC document

Stakeholders – At minimum this should include representatives from the three GPs, or if

agreed by the surgeries, representation of the GPs by the PCN. Other stakeholder will

include services commissioned under the PCN. This group should be bound to the project

through a memorandum of understanding.

Healthcare Planner – Specialist able to provide planning and development advice for

healthcare services and facilities. Working with stakeholders and the design team, they will

ensure the OBC responds to the specific requirements of patients in Kempston and the

wider PCN.

Project Board

Finance/ Funding

WorkstreamDesign Team

ArchitectStructural/

Civil Engineer

Plannning M&E

Ground surveys

Business Case Author

Stakeholders

Cater Street King Street

St JohnsOther

stakeholders

Healthcare Planner

Project Manager




Governance Arrangements

As the project moves forward, it is expected that the Council will remain a stakeholder, however

the project will be led by BCCG under their remit of providing primary care health services.

The change to the lead organisation is not unusual and reflects the needs of the project and the

position of the CCG to fulfil them. Primarily the CCG as project lead will be best place to access

NHS funding needed to take the project through OBC and FBC. The Council is expected to remain

involved in the project as a stakeholder.

6.3.1 ICS Estates Governance

Formal approval of the SOC will be sought form BBC, BCCG and in turn NHSI/NHSE. It will also

need to be adopted by BLMK ICS which has commenced its formation and will continue to

consolidate its care strategy for the area over the coming years.

Operation of the buildings

There are a range of active solutions where multiple stakeholders have come together to work in

and operate a building. This section will look firstly at how the three GP surgeries can operate

together before moving on to discuss the other stakeholder organisations.

6.4.1 GP Merger

Merging the three GP practise into a single entity offers the most efficient solution for operating an

MCCC. By coming together as a single organisation, the new combined practice is able to make use

of economics of scale within back-office and administrative functions.

A single organisation also simplifies the legal occupation of the building with a single tenant paying

a landlord without the need for subleases and licences. However, mergers of GP practices are

complex and can take a number of years to complete.

6.4.2 Co-location

If the GP practices wish to retain their individual legal structures and enter the building the can do

so as individual tenants or as subtenants of one of the practices. The first option provides for all

practices to be on an equal footing and have a direct relationship with the landlord. This option is

dependent on a willing landlord and some may be unwilling to lease to multi tenants due to an

increase in risk and management costs.

Should this pose a problem, one surgery, acting as head tenant could be used to resolve the issue.

The head tenant would take on responsibility for the building from the landlord, taking a lease for

the whole building then subletting it to the other surgeries. The risk is therefore held by the head

tenant should one of the other practices fail to pay their rent or share of the service charge. It also

places additional administrative burden on the head tenant as their need to issue rental invoices

and manage repair/maintenance responsibilities for the building.

As PCNs become more established and the practise within each PCN work ever closer together

services and resources will be increasingly shared. It is therefore possible that what started as a

co-location could overtime turn into a merger and whatever occupational arrangement is

undertaken at the start would not prevent this from happening.




Organisational Changes

6.5.1 MCCC Structure

A range of organisational structures can be employed to ensure the robust operation of the MCCC.

Whilst this will require further and more detailed analysis and commitment from stakeholders in

the OBC and outline of potential options has been considered in the following section. Each option

has a number of pro’s and con’s which should be considered in detail by each surgery. Surgeries

may also wish to seek professional legal counsel in considering these options.

6.5.1.1 Co-location

Of the potential options, co-locating within the same building is the fastest and simplest to achieve.

Each surgery retains its own pre-existing legal and staffing structure and moves into the new

MCCC.

As there are no legal changes to the organisations, save for their address, implementation can be

done quickly and with minimal risk. In addition, each surgery is able to retain its own identity and

established working practices – an important consideration in any small business.

However, this brings a number of inefficiencies. Invariably back office and support services have to

be duplicated and the surgeries miss out on economics of scale that might help to reduce the

number of non-medical staff. In primary health care hubs where this has happened is it not

unusual to find each surgery having its own receptionist, facilities contracts store rooms et al.

Co-location inevitably makes for a more complicated leasing structure as each requires a legal

agreement to occupy space in the building. Two solutions can be employed, but this is subject to

the building’s freeholder or landlord.

If the landlord is willing to contract with each surgery, it can issue separate leases for occupation.

However, it can be difficult to determine the responsibility for communal elements of the building

and landlords in general prefer to contract with as few parties as possible.

The main benefit to the surgeries is include equal legal footing within the building.

NHS Property Services remains the most likely landlords to offer leases to multiple surgeries.

Private landlords will be significantly less inclined.

The alternative solution would be for a head tenant to contract directly with the landlord and take

the other surgeries as subtenants. This option would be preferable to the majority of landlords as it

simplifies the management of the building and resolved the uncertainty around the communal

elements.

However, it requires a surgery that is willing to take on this additional responsibility and for the

remaining surgeries to take secondary positions within the legal structure of the building. Whilst in

principal this may work, the parties involved may, for their own reasons, be unwilling to contract in

this format.

Each option has an implication on the rentable space. The amount of space allocated for rental and

its makeup is contained in Table 15 and Table 18.

6.5.1.2 Merger

It is noted that the three surgeries are not perusing any intention to merge at this time. Whilst it is

not the remit of this document to comment on the intention of the three surgeries to merge, if the




practices were to come together through merger, they would create a single entity which would be

more efficient, both operationally and in taking a single lease of the whole building.

The merging of GP practices is a complex and lengthy process. Whilst the development of a new

MCCC should not force GPs to merge, should they wish to explore this, the following key actions

and decisions have been provided as a guide.

Activity Description

Due Diligence A due diligence questionnaire will be completed by each of the partners (GPs) to provide a schedule of assets and liabilities in order that everything

transferring is correctly documented and would focus in particular upon requirements for third party consents (e.g. to transfer/re-grant of GMS Contracts, key IT contracts, etc.).

Employment Terms

A review of the employment terms is taking place in order that advice can be provided on TUPE consultation and harmonisation. The terms for the retirement of any exiting partners will also need to be concluded.

Partnership Agreement

A new partnership agreement is being prepared between the partners of the merged practices to deal with a range of issues including:

Profits split and opening capital contributions

Ability to appoint non-medical partners and deal with conflicts

Decision making/meetings

Restrictions on competition

Entitlement to personal income

Rights to absence/leave

Duties and responsibilities

Entitlements on departure.

Heads of Terms Prepared to reflect the partners' agreed in principle position and avoid scope

for further debate as the Transaction proceeds.

Legal Arrangements

Suitable legal arrangements will need to be put in place to govern the rights and responsibilities of the shareholders/members in that company.

Property Documents

Depending upon the “vehicle” used, freehold titles or leases are will need to be submitted.

Table 14 – Key tasks for merger of GP surgery

6.5.2 Assumptions that have been taken forward

It is assumed in this SOC that the three practices would remain separate entities, although would

seek to gain efficiencies through their association in the PCN. It is also assumed that all three

practices would dispose of their existing buildings and move to the new MCCC.




6.5.3 Areas where further work is required

The OBC will provide the opportunity to investigate in more detailed the preferred legal structure of

the three practices. This may also be influenced by the building’s provider/developer and their

preference for managing the completed development.

A commitment will also need to be sought from the three practices to move into the completed

development. This will be subject to their ability to terminate agreements for occupation at their

existing premises and/or disposing of any surplus buildings. Cater Street, as the smallest of the

practices, should it decide not to move to the MCCC, will have only a marginal impact on the

proposal set out in this SOC. The two other practices, which have more patients, have a greater

influence on the size and function of the MCCC should they decline to progress with the scheme.

Commitments will need to be sought during the OBC and any adjustments made accordingly.




7 Conclusion

The Project Team assembled for the development of this SOC has represented a joined up

approach to primary healthcare between the CCG, GPs and the local authority.

The SOC has reconfirmed that the existing primary care health estate is not able to provide the

residents of Kempston with a sufficient space to fulfil GP obligations and will be ill equipped to

respond to the emerging commitments of Primary Care Networks and out of hospital services.

Kempston is already heavily developed and all of the surgeries within the town are aging and

incapable of being expanded to meet present day or future requirements. They are already unable

to accommodate a full range of out of hospital services.

Despite the density of development in Kempston, two potential sites have been identified. Of these

two sites, the Kempston Police Station has been identified and is highly suitable as a future MCCC.

Initial discussions with Bedfordshire Police have confirmed that they are already preparing to

vacate and dispose of the site. The Police Force are expected to dispose of the site in line with the

expected timescales of the OCB and FBC process. Finding new public sector uses for existing sites

is one of the Governments objectives and helps to keep public sector money in the system. It may

also promote a more collaborative approach to the exchange of the sites.

Initial assessments of the Police Station site have identified the police hold a clean and unrestricted

title of the site. Its existing 24-hour use is likely to be beneficial during the planning processes. The

site already has a number of existing junctions with the public highway, close proximity to public

transport and a central location within the town centre, all of which minimise the transport and

accessibility impact of consolidating all three Kempston GP surgeries in a single MCCC.

Summary of recommendations

Our recommendations are:

1 A new MCCC is needed to address the significant shortfall primary estate and respond

to new special requirements of the PCN demands as the three current sites are unable

to meet the needs of the local population in their current or a modified form.

2 Two suitable sites have been identified in this study, although the Police Station site

has been identified as the preferred site and there should be an ongoing dialogue with

the police to ensure that the site is not lost.

3 An initial accommodation schedule has been developed and a large number of

stakeholders have expressed an interest in using the MCCC as their primary location

for working with patients. The revenue costs will need to be developed in the OBC and

commitments made by the stakeholders to ensure the completed building provides an

appropriate amount of space.

4 Any expansion to the existing PCN will increase the rental obligations of GPs and the

CCG. A rent of £353/sqm is needed to deliver this proposal. However, as this scheme

is at SOC stage a significant amount of risk and therefore cost are present in the

appraisal. As the MCCC concept is developed and de-risked, it is expected that

contingent sums can be reduced and the revenue needed for this proposal reduced.

5 BBC and BCCG should recommend that this proposal is progressed to OBC stage, and

that the resources are identified to support this.

Next Steps

The following are suggested next steps for the project:




a The SOC will need to be reviewed by the procuring organisations, namely the BBC and BCCG

with feedback included prior to moving to approval by each organisation’s governing body.

b If the SOC is approved, formal agreement to proceed to OBC will need to be made by the CCG.

c The CCG, as the main health providing body within this project will need to identify appropriate

sources of funding for the delivery of the overall scheme and necessary funding for the

production of the OBC. This may be internal funding or government led. Whilst at the time of

writing no funds have been announced, it is widely expected that a call for proposal will be

launched later in 2020.

d Continue to work with stakeholders and move towards developing a Memorandum of

Understanding with interested parties. This will set out the objectives of each stakeholder and

the extent to which they are willing/able to commit to the project. This will play a significant

role in crystallising the requirements of the OBC.

e The OBC will need to developed to confirm the following:

Review and confirm the Case for Change and Critical Success Factors

Review and confirm the options

Develop the short-listed options to RIBA Stage 2

Develop a cost plan per option

Re-determine the best value for money solution

Re-determine the Procurement Strategy

Confirm funding and affordability

Confirm the management plan for delivery

Support and approval to progress to FBC.




Appendix 1. Other National Policies

Government Estate Strategy, July

2018

This Cabinet Office produced strategy develops on from the

previously developed estate strategy of 2014 and therefore builds

on plans rather than laying the foundations. For example it

highlights in its forward (page 02), “policies have already

provided an estate that is cheaper and easier to run and allows

more houses to be built on surplus government land. Creating a

network of Government Hubs has also helped make it easier for

public servants to work across the UK, within workplaces that

promote Smarter Working and collaboration across traditional

departmental boundaries”.

The strategy aims to ensure that the government estate “deliver

an estate that can adapt and respond”…”one that is leaner and

more agile, and equipped with better ways of working, mobile

technology and workplace design.”

The strategy in its introduction (page 08) goes on to highlight,

“Improving efficiency is key to a smarter state, and using

property differently has a major part to play. For example, central

and local government are working together on the One Public

Estate (OPE) programme to bring frontline services under one

roof, such as Jobcentre Plus offices and local authority benefits

services.” Key to this business case is highlighted in page 16, that

the strategy aims to achieve (by the end of the Parliament),

“support major estate transformation programmes, from

digitising justice services to implementing the findings of the

independent report by Sir Robert Naylor (Naylor review) to

transform the NHS England Estate.”

The Government response to the

Naylor Review, January 2018

The document in its forward quickly highlights that improvements

in the NHS estate are required, “…if we want to deliver world-

class care, we need world-class buildings in which to deliver it.

Many of the NHS’s healthcare facilities – hospitals, health centres,

GP surgeries – are excellent, but others could be better. They can

be more efficient, more attractive, better maintained, and more

effectively used to support clinical quality”.

This document sets out “the actions the Government will take in

response to the findings of the Naylor Review. We agree with his

primary conclusion that the NHS must manage and use its estate

more efficiently and strategically, whether by selling land and

buildings that it no longer needs to deliver clinical services or

using that land to develop new services in line with modern

thinking or to provide housing for NHS staff.”

Of particular importance to this business case, the document

highlights on page 16, “All STPs should be continuing to develop




their estates strategies with the support of their Strategic Estates

Advisers. For those bids which have already been supported and

those which hope to be in the future, STPs will be expected to

agree and submit an estates strategy prior to any funding being

released – this will need to include disposals plans as set out in

section 6. STPs will also be expected to ensure that they

maximise opportunities for self-funding of schemes using

their own capital, receipts from land disposals and use of

private finance where this provides value for money (eg

LIFT).” The response document goes on to highlight, “STPs

should, as part of the capital planning process and with support

from strategic estates advisers, NHSE, NHSI and the Department,

identify which projects could make effective use of private

financing through LIFT, PF2 and public private

partnerships (PPP).”

On page 19, the document highlights “Organisations will only

receive additional government funding through the STP capital

programme if they can demonstrate that they are pursuing all

value-for-money opportunities to generate capital within the STP

footprint and are reducing running costs by improving estates

utilisation and tackling backlog maintenance.”

NHS Property and Estates, Why

the estate matters for patients,

March 2017

This review published in March 2017 considered “the options open

to the NHS to achieve best value, from NHS property, in

alignment with the delivery of the vision set out in the 5YFV, and

to support a small number of high value property transactions in

London”. It found, “the general consensus is that the current NHS

capital investment is insufficient to fund transformation and

maintain the current estate. We estimate that STP capital

requirements might total around £10bn, with a conservative

estimate of backlog maintenance at £5bn and a similar sum likely

to be required to deliver the 5YFV. This could be funded through

property disposals, private capital (for primary care) and from HM

Treasury. However, the NHS needs to develop a robust capital

strategy to determine the final investment requirements through

the STP plans.

It highlighted 17 specific recommendations which fell into three

main areas: “how we can improve our capability and capacity,

support action at a local level and develop a robust and

sustainable strategy that enables the estate to support

transformation in the NHS”.

Important for this business case is recommendation 11 which

states “At a minimum, the Department of Health (DH) and HM

Treasury (HMT) should provide robust assurances to STPs that

any sale receipts from locally owned assets will not be recovered

centrally provided the disposal is in agreement with STP plans.

This report recommends that HMT should provide additional




funding to incentivise land disposals through a “2 for 1 offer” in

which public funds match disposal receipts.”

Also recommendation 17 applies to this scheme: “Substantial

capital investment is needed to deliver service transformation in

well evidenced STP plans. We envisage that the total capital

required by these plans is likely to be around £10bn, in the

medium term, which could be met by contributions from three

sources; property disposals, private capital (for primary care) and

from HMT.”

Next steps on the NHS Five Year

Forward View, March 2017

In March 2017 NHS England (NHSE) published an update on its

Five Year Forward View. The documents highlights on page 4 that

“some urgent care services are struggling to cope with rising

demands. Up to 3 million A&E visits could have been better dealt

with elsewhere.” This therefore will rely on providing more

community based infrastructure support the joined up care and

support services. The documents goes on to highlight that “over

the next two years the NHS will take practical action to take the

strain off A&E. Working closely with community services and

councils, hospitals need to be able to free up 2,000-3,000

hospital beds. In addition, patients with less severe conditions will

be offered more convenient alternatives, including a network of

newly designated Urgent Treatment Centres, GP appointments,

and more nurses, doctors and paramedics handling calls to NHS

111.”

The multispecialty community

provider (MCP) emerging care

model and contract framework,

July 2016

This document describes what being an MCP means, based on

assembling the core features from the 14 MCP vanguards into a

common framework. This document highlights in its introduction

that “an MCP is about integration. As a patient or a clinician, you

would not choose to recreate from scratch the historical partitions

between primary, community, mental health and social care and

acute services. The boundaries make it harder to provide joined-

up care that is preventative, high quality and efficient. The MCP

model dissolves the divides. It involves redesigning care around

the health of the population, irrespective of existing institutional

arrangements. It is about creating a new system of care delivery

that is backed up by a new financial and business model”. The

underlying logic of an MCP is that by focusing on prevention and

redesigning care, it is possible to improve health and wellbeing,

achieve better quality, reduce avoidable hospital admissions and

elective activity, and unlock more efficient ways of delivering

care. The document goes onto highlight:

“An MCP opens up new options for partners, clinicians and

managers. Over time it should also help with managing demand

for general practice, by building community networks, connecting




with the voluntary sector, and supporting patient activation and

self-care.”

“An MCP may start off as a loose coalition, but sooner or later it

has to be established on a sound legal footing under contract.”

“The fully integrated MCP contract will be a new streamlined

hybrid of the NHS standard contract and a contract for primary

medical services. It will set national and local service

requirements and standards. Contract duration will be much

longer than is usual for an NHS standard contract: 10 or 15

years. Payment to the MCP will comprise three parts: (i) a whole

population budget for the range of services covered; (ii) a new

performance element that replaces CQUIN and QOF; and (iii) a

gain/risk share for acute activity.”

“The contract could be held by entities such as a community

interest company, a limited liability company or a partnership

(e.g. building out from a GP federation or super-partnership), or

by a statutory NHS provider. It opens up the prospect of new

options for how GPs and other clinicians could relate to the MCP,

but will not compel an existing practice to leave the security of its

general medical services (GMS) contract in perpetuity.”

GP Forward View,

April 2016

The General Practice (GP) Forward View (April 2016) sets a new

direction and opportunity to demonstrate what a strengthened

model of general practice can provide to patients, those who work

in the service, and for the sustainability of the wider NHS.

In the introduction on page 4, Simon Stevens clearly articulates

the importance of GP’s for the NHS, “GPs are by far the largest

branch of British medicine. A growing and ageing population, with

complex multiple health conditions, means that personal and

population-orientated primary care is central to any country’s

health system. As a recent British Medical Journal headline put it

– “if general practice fails, the whole NHS fails”. He went on to

highlight in terms of investment in primary care, “…by 2020/21

recurrent funding to increase by an estimated £2.4 billion a year,

decisively growing the share of spend on general practice

services, and coupled with a ‘turnaround’ package of a further

£500 million. Investments in staff, technology and premises, and

action on indemnity and red tape.”

Five Year Forward View, October

2014

This five year forward view highlights in the Executive Summary:

“This ‘Forward View’ sets out a clear direction for the NHS –

showing why change is needed and what it will look like. Some of

what is needed can be brought about by the NHS itself. Other

actions require new partnerships with local communities, local

authorities and employers. Some critical decisions – for example

on investment, on various public health measures, and on local




service changes – will need explicit support from the next

government

Interestingly for this business case, item 8 of the executive

summary points out some of the new service models along with

their progress, being adopted across the Country. “One new

option will permit groups of GPs to combine with nurses, other

community health services, hospital specialists and perhaps

mental health and social care to create integrated out-of-hospital

care - the Multispecialty Community Provider. Early versions

of these models are emerging in different parts of the country,

but they generally do not yet employ hospital consultants, have

admitting rights to hospital beds, run community hospitals or take

delegated control of the NHS budget. It goes on to highlight in

Item 9, page 4; “A further new option will be the integrated

hospital and primary care provider - Primary and Acute Care

Systems -combining for the first time general practice and

hospital services, similar to the Accountable Care Organisations

now developing in other countries too”.




Appendix 2. Stakeholders

List of stakeholders and when meetings took place.

Date Attendees Organisation

29th August 2019 Ruth Bradley East London NHS Foundation Trust

29th August 2019 Sarah Lister, Margaret Birtles, Jacqueline Gray

One Public Estate

11th September 2019 Mayor; Christopher Roe; Claire Colgan; Olivia Quinn

Mayor & Councillor Jackson

17th September 2019 Jacqueline Gray; Cllr Sue Oliver; Cllr James Valentine; Cllr Kay Burley;

Kempston Councillors Meeting

25th September 2019 Lorraine Chown; Margaret Birtles; Police Estates

26th September 2019 Colin Foster; Ben Pearson; Children's Services

26th September 2019 Kate Ellis; Jackie Golding; Bedfordshire Rural Communities Charity

3rd October 2019 Michelle Bradley; Francis Barnacle; ELFT Mental Health & Wellbeing

services

8th October 2019 Robert Freake; Simon Harwin; Cambridgeshire Community Services - Children Services

14th October 2019 Amanda Philips Circle MSK

23rd October 2019 Nicky Wadely; Carrie Walker; Nikki Barnes; BCCG

28th October 2019 Claudia Montgomery Strategic Estates, NHS England




Appendix 3. GP Interviews

Meeting Date Document

King Street Surgery, Kempston 13th August 2019

Kempston

MCCC_Wootton GP Practice SOC - Minutes of Meeting with King Streeet.pdf

Cater Street, Kempston 13th August 2019

Kempston

MCCC_Wootton GP Practice SOC - Minutes of Meeting with Cater St.pdf

St Johns, Kempston 13th August 2019

Kempston

MCCC_Wootton GP Practice SOC - Minutes of Meeting with St Johns - Rev1.pdf




Appendix 4. Risk Register

Category Risk Title Risk Description/ Narrative

Consequence Prob. Impact Risk Rat-ing

Mitigating Action

Commercial Macro-economic risks

Market conditions, specifically the potential adverse impact that the political uncertainty of Brexit may cause on the project and or the sites identified.

Sites could become unviable.

3 3 9

Conducting sensitivity analysis and ensuring the SOC report is relevant

Stakeholders Contradictory info. from stakeholders

Contradictory messages and requirements during discovery phase requiring ratification and clarification.

No clear outcome for the SOC

3 2 6

Robust governance and defined approval processes to be put in place

Site Site lost

A preferred site is lost to another development due to time scales of approval for SOC/OBC/FBC.

SOC becomes obsolete

3 4 12

Ongoing dialogue with landowners of preferred sites to communicate time scales

Report SOC Approval

Report not ratified by partner organisations


2 4 8

Cross partner representation on the Project Team

Report SOC Approval - NHS

Report is not approved by NHS


2 4 8

Work with SEA and partnering bodies to ensure SOC meets

requirements

Stakeholders Change of needs

Stakeholders change their needs therefore changing the area required in the MCCC

The SOC calculated areas will be invalid.

3 1 3

Ensure their needs (and the potential for change) is understood

Stakeholders Political Change

Change in Councillors/Mayor changing the needs


2 2 4 Ensure buy in by Councillors

Programme Programme

Stakeholders cannot

be consulted in time for input into the SOC

Stakeholders' views are not represented in the SOC

1 3 3

Ensure stakeholders

are contacted as early as possible

Programme Delivery of SOC

SOC cannot be delivered in time

Sites may be lost; Wave 5 may be missed

2 1 2

Ensure programme is reviewed and NHS Christmas shutdown is taken into account.




Appendix 5. Site assessment criteria

Criteria Points

1 Access

1.1 Is the site next to multiple bus routes 5

1.2 Is the site next to a bus routes 5

1.3 Is the site in a suitable area 5

1.4 Can a junction be formed with the main highway or is there an existing junction 5

2 Impact

2.1 Does the site avoid estate roads which may become congested with additional traffic 5

2.2 Is the site centrally located to existing GP surgeries 2

2.3 Can surrounding parking be utilised 5

2.4 Will there be an ecological impact to the development 3

2.5 Does the site have restrictions on development (protected open space) 3

3 Functionality

3.1 Is the location suitable for 24/7 working 5

3.2 Is the site suitable for 24 hour working 4

3.3 Is there sufficient onsite parking 5

3.4 What is the flood risk rating 2

3.5 Are there any complimentary services in the vicinity 3

4 Deliverability

4.1 Can the site accommodate what is required? 5

4.2 Is there room for future expansion 1

4.3 Is the site in public body ownership 3

4.4 Is the site vacant 2

4.5 Does the site align with the project’s timescales 4

4.6 Is there certainty of acquisition 2

4.7 Are there any identifiable planning issues 2

4.8 Are there any development controls in place 2

5 Total 390




Appendix 6. Site Scores

Site 1

Site 2

Site 3

Site 4

Site 5

Site 6

Site 7

Site 8

+ S

ite

9Site 1

0Site 1

1Site 1

2Site 1

3Site 1

4Site 1

5

Moori

ngs

Beatr

ice

Str

eet

Land a

dj

Kem

psto

n

Pool

Addis

on

How

ard

Park

Kem

psto

n

Police S

tation

Saxon

Centr

e

Robert

Bru

ce

School

Land a

dj BT

Offic

es a

nd

Offic

es

80 B

unyan

Road

Land n

ext

to

pum

pin

g

sta

tion

Kem

psto

n

Am

bula

nce

Sta

tion

Land n

ext

to

Baliol

Pri

mary

School

Land n

ext

to

Challenger

Academ

y

Bedfo

rdshir

e

Police H

Q

Access

Is t

he s

ite n

ext

to m

ultip

le b

us r

oute

s5

33

14

23

32

Is t

he s

ite n

ext

to a

bus r

oute

s5

33

34

23

33

0

Is t

he s

ite in a

suitable

are

a5

11

25

33

32

Can a

junction b

e form

ed w

ith t

he m

ain

hig

hw

ay

or

is t

here

an e

xis

ting junction

51

33

05

31

51

Impact

Does t

he s

ite a

void

esta

te r

oads w

hic

h m

ay

becom

e c

ongeste

d w

ith a

dditio

nal tr

affic

51

11

31

33

1

Is t

he s

ite c

entr

ally locate

d t

o e

xis

ting G

P

surg

eri

es

21

11

43

32

2

Can s

urr

oundin

g p

ark

ing b

e u

tilised

51

11

32

11

1

Will th

ere

be a

n e

colo

gic

al im

pact

to t

he

develo

pm

ent

33

33

53

45

3

Does t

he s

ite h

ave r

estr

ictions o

n d

evelo

pm

ent

(pro

tecte

d o

pen s

pace)

31

33

32

33

2

Functionality

Is t

he location s

uitable

for

24/7

work

ing

51

13

53

35

2

Is t

he s

ite s

uitable

for

24 h

our

work

ing

41

13

53

34

2

Is t

here

suffic

ient

onsite p

ark

ing

53

21

03

32

32

What

is t

he flo

od r

isk r

ating

21

33

33

30

33

Are

there

any c

om

plim

enta

ry s

erv

ices in t

he

vic

inity

31

13

32

21

1

1.4

D

elivera

bility

can t

he s

ite a

ccom

modate

what

is r

equir

ed?

53

21

30

30

00

02

Is t

here

room

for

futu

re e

xpansio

n1

41

13

22

31

Is t

he s

ite in p

ublic b

ody o

wners

hip

34

33

21

33

3

Is t

he s

ite v

acant

22

33

22

21

3

Does t

he s

ite a

lign w

ith t

he p

roje

ct’s t

imescale

s4

33

33

22

13

Is t

here

cert

ain

ty o

f acquis

itio

n2

33

33

13

23

Are

there

any identifiable

pla

nnin

g issues

21

23

42

34

3

Are

there

any d

evelo

pm

ent

contr

ols

in p

lace

22

33

32

33

2

Tota

l390

39%

42%

44%

-200%

74%

-100%

47%

-100%

-52%

-100%

-44%

-100%

41%

-100%

Bla

ck M

ark

Score

00

02

01

01

11

11

01

Maxim

um

Poin

ts




Appendix 7. Presentation to Mayor of Bedford

Meeting Date Document

Presentation of Key Findings to

Mayor of Bedford

1st December 2019

Summary of Findings

Report - Briefing Paper.pdf




Appendix 8. Police Station Site Financial Appraisal

Income

GMS Contract

Valuation Quantity Units Value FI Factor PA Rent

Consultation/Treatment Space 352 sqm £353.15 100% £124,309

Associated Patient Waiting Space 181 sqm £353.15 100% £64,019

Associated Office/Administrative 288 sqm £353.15 100% £101,707

Meeting Rooms 73 sqm £353.15 100% £25,780

Pharmacy 24 sqm £353.15 100% £8,476

Planning Allowance @10% 91.828 sqm

100% £0

Engineering Allowance @20% 183.656 sqm

100% £0

Circulation Allowance @20% 183.656 sqm £353.15 100% £64,858

Parking 66 bays £235.00 100% £15,510

Total Annual Income from GMS 1377 sqm £404,659

PCN Contract

Valuation Quantity Units Value FI Factor PA

Multi-function Rooms 325 sqm £353.15 100% £114,774



Meeting Rooms 0 sqm £353.15 100% £0

Pharmacy 0 sqm £353.15 100% £0


100% £0


100% £0


Parking 39 bays £235.00 100% £9,165

Total Annual Income from PCN 894.6 sqm £261,897

Total Annual Income for Building 2272 sqm £666,555

Table 15 – Estimated Income of Police Station site




Cost

Land Assembly

1 Land Value £1,100,000 @ 1.3 acres £1,430,000

2 Risk Factor £1,430,000 @ 0%

£1,430,000

3 Demolition/Remediation

£583,560

4 Residual Land Value £846,440

5 Stamp Duty Land Tax

£31,822

5 Vendors Agents Fees £846,440 @ 1%

£8,464

6 Vendors Legal Fees £846,440 @ 1%

£8,464

7 Total Land Cost £895,191

Construction Costs

1 Demolition

£583,560

2 Works to Existing

£0

3 New Build £1,075 @ 2272

£2,442,400

4 Fit out Allowance £1,550

2272

£3,520,852

5 Car Park

£232,000

6 External Works

£890,400

Sub total £3,376

£7,669,212

7.1 Prelims £7,669,212 @ 13%

£997,000

7.2 OH&P £8,666,212 @ 5%

£433,000

Total Construction Cost

£9,099,212

8.1 Professional Fees £9,099,212 @ 13%

£1,183,000

8.1.1 OBC/FBC £9,099,212 @ 3%

£273,000

8.2 Trust Works £9,099,212 @ 2%

£182,000

8.3 Non Works £9,099,212 @ 1%

£91,000

8.4 Equipment / IT £2,272 @ 200

£454,397

9.1 Risk Allowance £11,282,609

10%

£1,128,000

9.2 Optimism bias £12,410,609

10%

£1,241,000

Total Build Cost £6,009 2272 £13,651,609

Total Cost £14,546,800




Table 16 – Development Appraisal of Police Station site

NPV over 25 years

NPV has been calculated with a target rate of return of 3% and a rental growth of 2.5% pa reviewed at 5

year intervals on an upwards only basis.

Periods Future Income Run. Cost Balance Dis.Factor PV

0 -£14,546,800

-£14,546,800

1 £666,555

£666,555 1.03 £647,141

2 £666,555 £0.00 £666,555 1.06 £628,292

3 £666,555 £0.00 £666,555 1.09 £609,993

4 £666,555 £0.00 £666,555 1.13 £592,226

5 £666,555 £0.00 £666,555 1.16 £574,977

6 £754,146 £0.00 £754,146 1.19 £631,586

7 £754,146 £0.00 £754,146 1.23 £613,190

8 £754,146 £0.00 £754,146 1.27 £595,330

9 £754,146 £0.00 £754,146 1.30 £577,990

10 £754,146 £0.00 £754,146 1.34 £561,156

11 £853,247 £0.00 £853,247 1.38 £616,404

12 £853,247 £0.00 £853,247 1.43 £598,450

13 £853,247 £0.00 £853,247 1.47 £581,020

14 £853,247 £0.00 £853,247 1.51 £564,097

15 £853,247 £0.00 £853,247 1.56 £547,667

16 £965,371 £0.00 £965,371 1.60 £601,587

17 £965,371 £0.00 £965,371 1.65 £584,065

18 £965,371 £0.00 £965,371 1.70 £567,054

19 £965,371 £0.00 £965,371 1.75 £550,538

20 £965,371 £0.00 £965,371 1.81 £534,503

21 £1,092,229 £0.00 £1,092,229 1.86 £587,127

22 £1,092,229 £0.00 £1,092,229 1.92 £570,026

23 £1,092,229 £0.00 £1,092,229 1.97 £553,423

24 £1,092,229 £0.00 £1,092,229 2.03 £537,304

25 £1,092,229 £0.00 £1,092,229 2.09 £521,655

Total

£0.00

Table 17 – NPV of Police Station site




Appendix 9. Robert Bruce Financial Appraisal

Income

GMS Contract

Valuation Quantity Units Value FI Factor PA Rent

Consultation/Treatment Space 352 sqm £353.15 100% £124,309



Meeting Rooms 73 sqm £353.15 100% £25,780

Pharmacy 24 sqm £353.15 100% £8,476


100% £0


100% £0


Parking 66 bays £235.00 100% £15,510

Total Annual Income from GMS 1377 sqm £404,659

PCN Contract

Valuation Quantity Units Value FI Factor PA

Multi-function Rooms 325 sqm £353.15 100% £114,774



Meeting Rooms 0 sqm £353.15 100% £0

Pharmacy 0 sqm £353.15 100% £0


100% £0


100% £0


Parking 39 bays £235.00 100% £9,165

Total Annual Income from PCN 894.6 sqm £261,897

Total Annual Income for Building 2272 sqm £666,555

Table 18 – estimated revenue of former Robert Bruce Middle school site




Cost

Land Assembly

Land Value £1,100,000 @ 1.2 acres £1,320,000

Risk Factor £1,320,000 @ 0%

£1,320,000

Demolition/Remediation

£0

Residual Land Value

£1,320,000

Stamp Duty Land Tax

£55,500

Vendors Agents Fees £1,320,000 @ 1%

£13,200

Vendors Legal Fees £1,320,000 @ 1%

£13,200

Total Land Cost £1,401,900

Construction Costs

1 Demolition

2 Works to Existing

£0

3 New Build £1,075 @ 2272

£2,442,400

4 Fit out Allowance £1,550

2272

£3,520,852

5 Car Park

£232,000

6 External Works

£890,400

Sub total £3,119

£7,085,652

7.1 Prelims £7,085,652 @ 13%

£921,000

7.2 OH&P £8,006,652 @ 5%

£400,000

Total Construction Cost

£8,406,652

8.1 Professional Fees £8,406,652 @ 13%

£1,093,000

8.1.1 OBC/FBC £8,406,652 @ 3%

£252,000

8.2 Trust Works £8,406,652 @ 2%

£168,000

8.3 Non Works £8,406,652 @ 1%

£84,000

8.4 Equipment / IT £2,272 @ 200

£454,397

9.1 Risk Allowance £10,458,049

10%

£1,046,000

9.2 Optimism bias £11,504,049

10%

£1,150,000

Total Build Cost £5,570 2272 £12,654,049

Total Cost £14,055,949

Table 19 – Development Appraisal of former Robert Bruce middle school site




NPV over 25 years

Periods Future Income Running Cost Balance Discount Factor PV

0 -£14,546,800

-£14,055,949

1 £666,555

£666,555 1.03 £647,141

2 £666,555 £0.00 £666,555 1.06 £628,292

3 £666,555 £0.00 £666,555 1.09 £609,993

4 £666,555 £0.00 £666,555 1.13 £592,226

5 £666,555 £0.00 £666,555 1.16 £574,977

6 £754,146 £0.00 £754,146 1.19 £631,586

7 £754,146 £0.00 £754,146 1.23 £613,190

8 £754,146 £0.00 £754,146 1.27 £595,330

9 £754,146 £0.00 £754,146 1.30 £577,990

10 £754,146 £0.00 £754,146 1.34 £561,156

11 £853,247 £0.00 £853,247 1.38 £616,404

12 £853,247 £0.00 £853,247 1.43 £598,450

13 £853,247 £0.00 £853,247 1.47 £581,020

14 £853,247 £0.00 £853,247 1.51 £564,097

15 £853,247 £0.00 £853,247 1.56 £547,667

16 £965,371 £0.00 £965,371 1.60 £601,587

17 £965,371 £0.00 £965,371 1.65 £584,065

18 £965,371 £0.00 £965,371 1.70 £567,054

19 £965,371 £0.00 £965,371 1.75 £550,538

20 £965,371 £0.00 £965,371 1.81 £534,503

21 £1,092,229 £0.00 £1,092,229 1.86 £587,127

22 £1,092,229 £0.00 £1,092,229 1.92 £570,026

23 £1,092,229 £0.00 £1,092,229 1.97 £553,423

24 £1,092,229 £0.00 £1,092,229 2.03 £537,304

25 £1,092,229 £0.00 £1,092,229 2.09 £521,655

Total £490,851

Table 20 – NPV of former Robert Bruce middle school




Appendix 10. Cost benchmarking

W

oott

on V

ale

Kem

psto

n P

olice

Sta

tion

Selb

y C

om

munity

Pro

ject

Buckin

gham

shir

e H

ealth &

Care

Centr

e

Houghto

n le

Spri

ng P

rim

ary

Care

Centr

e

Pallio

n H

ealth

Centr

e,

Sunderland

3PD

led s

chem

e

appra

isal

Photo

PID

Pro

ject

SO

C P

roje

ct

Pro

vid

ed b

y

BCCG

Siz

e (

sqm

) (G

IA)

672

2,2

72

3,1

75

2,0

18

5,2

56

3,3

52

1,2

88

Constr

uction c

ost

£2,7

76,1

80

£8,9

81,6

49

£10,1

83,5

00

£8,3

47,8

26

£24,1

56,5

46

£15,5

43,8

82

£4,4

77,2

87

£/

sq

m

£4

,13

1

£3

,95

3

£3

,20

7

£4

,13

7

£4

,59

6

£4

,63

7

£3

,47

3

The a

bove p

rovid

es a

cost

com

pari

son o

f th

e p

roposed c

osts

of W

oott

on a

nd

Kem

psto

n a

gain

st

com

ple

ted p

roje

cts

els

ew

here

in t

he c

ountr

y.

The c

osts

have

been a

dju

ste

d for

the B

edfo

rd location facto

r to

allow

them

to b

e c

om

pare

d.

The c

onstr

uction c

osts

have b

een e

xtr

acte

d fro

m t

he a

ppra

isals

for

each p

roje

ct

with t

he follow

ing s

ite s

pecific

costs

or

costs

that

are

not

inclu

ded in t

he fin

al

cost

exclu

ded fro

m t

he a

bove fig

ure

to p

rovid

e a

lik

e for

like c

om

pari

son:

Land p

urc

hase

D

em

olition

Exte

rnal w

ork

s

O

BC/F

BC p

roduction c

osts

Ris

k a

llow

ance

O

ptim

ism

bia

s

Pre

lim

s a

nd O

H&

P a

ssocia

ted w

ith t

hese s

pecific

costs

Fin

ance

Kem

psto

n is b

igger

than W

oott

on s

o b

enefits

fro

m e

conom

ies o

f scale

. Both

buildin

gs a

lso h

ave a

Pla

nnin

g A

llow

ance w

hic

h o

ffsets

ris

k a

t th

is e

arl

y

sta

ge o

f th

e p

roje

ct

and m

ay b

e r

educed a

t O

BC,

reducin

g t

he s

ize o

f th

e

buildin

g a

nd o

vera

ll c

ost

of th

e p

roje

ct.

February 2020 Strategic Outline Case

Documents

Transcript of February 2020 Strategic Outline Case